Dr. Mulhall answers: The suggestion is that the traction device gives the greatest benefit to men with PD who use it for at least 4 hours per day for at least 6 months. You are in a slightly different population as you are using it after plaque incision and grafting. It sounds as if you are more than 6 months after surgery but you have only been using the traction device for a month so continue to use. If after another 5 months you see little change in length or curvature, it is not likely that you will see further improvement after that.close

A small percentage of patients have reported a history of having a prior short term episode of Peyronie's disease which corrected itself, only to come back months to years later with a plaque which does not correct itself. It does appear that repetitive injury may result in the worsening of the process resulting in a deformity which may then require more definitive treatment. Interestingly, patients who have had improvement as a result of intralesional verapamil injections have not been noted to have a recurrence with up to 15 years of follow-up.close

Dr. Levine answers: During the course of the study, patients were seen on a monthly basis and assessed for changes they noted. Overall what appeared to occur was that a few patients had measurable improvement after 1-2 months of therapy with a minimum of 4-6 hours a day. Typically by the second to fourth month, measured improvement was in stretched length gain, curvature reduction and girth enhancement. During the fourth to sixth months, some patients noted further improvement, but about 30% had mild discomfort with use of the device, which necessitated reducing the duration of traction or using fewer spacers to reduce the force the traction. It is presumed that this discomfort was associated with what is known as "tissue fatigue" and, by reducing the duration or the intensity of the traction, that there would be less discomfort. Currently, many patients are using daily traction along with verapamil injections. It appears that the response to treatment has a similar pattern to the pilot study. The key to success with traction is clearly daily use for at least 4-6 hours.close

Dr. Mulhall answers: You didn't mention how long you have had PD, which is an important factor in your prognosis. Potaba is in my opinion (based on currently available medical evidence) worthless. It is an expensive and poorly tolerated placebo. Even less effective is verapamil gel. There is good data that the verapamil never penetrates through the skin into the plaque. Surgery is reserved for men who have had PD for at least 12 months and have been stable for at least 3 months. [For further advice on the traction device see answers to questions in the treatment section.]close

Dr. Levine answers: The presentation of Peyronie's disease is variable from patient to patient; some patients notice a very rapid onset and progression, while others have a gradual onset. For most, the deformity will stabilize within 6-12 months, but repeated injury could prolong this process. If the deformity is severe enough and the deformity has been stable for at least 6 months, surgery may be considered. Prior to stabilization, use of nonsurgical treatments have been recommended to accelerate the stabilization process as well as stop progression. There may also be some reduction in deformity and improvement of overall sexual function. I would advise you to discuss this with your local Peyronie's disease expert.close

Dr. Levine answers: Loss of sensation is an unusual complaint for men with Peyronie's disease. But your situation may be because the deformity interferes with stimulation of the area on your penis which is important for sexual arousal. If indeed the curvature is responsible for the diminished arousability then correction of deformity may help. On the other hand if this is a sensory loss due to injury, then there is really no recognized treatment to recover nerve sensation in the penis. In men who have this complaint associated with Peyronie's disease or other causes, I do recommend massage and stretch therapy. The vitamin B complex vitamins have been also reported to be beneficial for nerve recovery, but this has not been supported in large-scale trials, and not at all in the penis. To determine whether the problem is a true sensory loss, biothesiometry, which is a measure of vibratory sensation, can be performed in the urologist office to evaluate the penile sexual sensation nerves.close

Dr. Levine answers: This is a good question which addresses a complex problem. Men who are born with congenital curvature or chordee typically have ventral, downward curvatures, but may have lateral or even dorsal curvatures. Depending upon the hardness of the erection and the pressures being placed on it, this could cause discomfort because of torque on the bent penis. If there is no palpable scar and the curvature has been present since you remember having erections, is it likely this is congenital curvature. On the other hand, men who have congenital curvature can possibly injure their penis which could result in scarring which can resemble Peyronie's disease and may in fact be Peyronie's disease. This is unusual in my experience, but I have seen men with scarring as a result of repetitive penile trauma.The primary treatment approach for those with no active scarring process is to perform penile straightening with tunica plication. This has a high success rate. Although traction therapy has been recommended for Peyronie's disease, there is little reported experience correction of deformity for men with congenital curvature.close

It is generally believed that PD becomes stable somewhere between 12-18 months after its onset. Many patients in my practice stabilize within the first 6 months but rare patients continue to have pain for up to 2 years. It is not likely that the penile pain being experienced by you is related to the original plaque. It is either related to another plaque or some other cause. Seeing a urologist who has an interest of specializes in PD is worthwhile.close

Men have reported an early episode of Peyronie's disease which resolves only to be followed anywhere from months to years later by a full blown expression of PD. Clearly further evaluation will be necessary with examination and possibly ultrasound. Should you not have any significant deformity and only the pain, it might be advisable to simply take anti-inflammatories to encourage reduction of the discomfort and to decrease the inflammation as well.close

It does appear that you now likely have stable Peyronie's disease, and at this point, evaluation by a Peyronie's expert would be in order. During this evaluation, complete evaluation would be necessary, as well as inducing an erection in the office, so as to visualize the deformity. Ultrasound may also be useful to evaluate penile vascular flow and to determine whether the plaque has bone within it. Depending upon the deformity, its severity and your erectile capacity, you may be a candidate either for nonsurgical treatment with oral medication, intralesional injections and possible traction therapy versus the most reliable way to fix Peyronie's disease with surgery. Clearly the most important thing is to get proper evaluation by a Peyronie's expert so that you can understand all your options.close

This sounds like a chordee and if indeed it is a new downward curvature, there may also be a component of Peyronie's. Usually, this type of deformity requires surgical correction although there have been some recent reports of success with downward curvature using external traction therapy with the FastSize penile extender. This type of nonsurgical treatment would be indicated as an effort to correct deformity without surgery if you have good quality erections, but if the erections are compromised in terms of their rigidity, then surgery with placement of prosthesis may be necessary. Clearly, the most important thing for you is to have a proper consultation and likely an evaluation of your erection in the office, possibly in concert with a penile duplex ultrasound so that the penile blood flow could be assessed, and to rule out the presence of calcification in your plaque.close

At this time there is no clear evidence to show that Viagra enhances penile health on the long-term. The other PDE-5 inhibitors, including Levitra and Cialis, have also been shown to improve blood flow into the penis and there is some suggestion that long-term use of any of these three drugs may reduce the risk of cardiac events over time. Until a properly done study is completed, I would not recommend taking daily PDE-5 medication for future penile health, as there is the possibility of side effects and this is quite an expensive medicine. On the other hand, for the man who is experiencing erectile dysfunction, daily to every other daily dosing with these medications may be in order.close

Peyronie's disease involves the jacket tissue which surrounds the vascular tissue of the penis. This jacket is known as the tunica albuginea and remains below the skin and subcutaneous tissues. Peyronie's disease therefore does not affect the penile skin in any way. Therefore, any changes happening on the shaft skin may represent a different problem that may be associated with certain medications or local injury. It would be wise to consider evaluation by a urologist and/or a dermatologist.close

What you describe may be a variant of Peyronie's disease, but to make the diagnosis the penis is typically evaluated in the flaccid condition, the glans is pulled out to stretch the penis and then the shaft can be palpated to identify the fibrotic scar tissue known as plaque. If there is no palpable plaque and yet there is deformity, this may be congenital, or it may be that Peyronie's disease is in the very early phase and has not yet manifested itself with a palpable plaque. I have recently seen a young man who described similar findings, where I could not identify Peyronie's disease, but he described changes in the penis in the flaccid condition only, but no deformity when erect. I have recommended the use of L-arginine and pentoxifylline. The latter must be prescribed by a physician as early treatment for fibrotic/scarring disorders. This treatment is relatively inexpensive, non-toxic, and may be beneficial. Certainly, should you find a deformity of the penis with a palpable plaque, then further, more aggressive treatment may be indicated.close

At this time, there are no recognized foods or beverages that may trigger Peyronie's disease or that can improve the condition. Although several drugs have historically been suggested to cause Peyronie's disease, including beta blockers, such as propranolol or possibly Dilantin, a treatment for seizure disorder, none of these have been shown in more current surveys to cause Peyronie's disease. It was likely that this was simply a coincidence that was recognized in a small population of men presenting with Peyronie's disease.close

The acute phase of Peyronie's disease is variable from patient to patient and may not include any pain. In addition, the onset of a painless palpable plaque may be the first indication of Peyronie's disease with subsequent or even immediate onset of deformity. Some patients will present with discomfort of the penis without a palpable plaque or deformity and may notice gradual appreciation of the plaque and deformity. Therefore, the widely-held presumption that the patient with Peyronie's disease presents first with pain followed by palpable nodule and then deformity needs to be modified as there is no uniform presentation. It also should be recognized that patients may present acutely with a calcified plaque and that a calcification is not necessarily a sign of a mature or an old plaque.close

This is a very important question and I am delighted that you are concerned enough to address it in this website. Peyronie's disease has been known for many years, but has recently been demonstrated in a proper trial to result in significant depression in the affected male. This is clearly because the penis is an important organ for men and for some, it truly defines them. Any alteration in the penis in terms of physical appearance or function can result in states of anxiety and mild to severe depression. Certainly, ignoring this problem will not help your husband and instead, I would recommend that you encourage him to see a qualified physician with experience in Peyronie's disease who may be able to offer treatment to stabilize or possibly resolve the problem. What is important to remember is that the goal of the physician is to prevent progression of the Peyronie's disease and also to try to restore function, but not necessarily to restore the appearance and condition of the penis to how it was before the Peyronie's disease occurred. Usually there will be some residual loss of length, possibly some residual curvature and maybe even some erectile dysfunction. Support from spouses, sexual partners and family will be very important to the successful recovery of the affected man. Occasionally the depression can be so severe that counseling, sex therapy or even psychiatric care may be necessary and beneficial.close

This deformity may indeed be a manifestation of Peyronie's disease. This would be determined by physical examination in the flaccid condition where a palpable scar may be noted towards the end of the shaft below the head of the penis on the right side for you. A right sided scar would prevent expansion of the penis on that aspect resulting in the right tilt. It is also possible that if there is no palpable scar, that there may be some disproportion to the elasticity of the penis on the left side, allowing greater expansion on the left, causing the tilting to the right. If the tilt is significant and interferes with sexual activity or causes cosmetic distress, this can be readily repaired with a simple outpatient operation.close

Dr. Levine answers: This question will be answered in 2 parts. One pertains to the severity of curvature which at 90 degrees is certainly a severe curve and the other is the duration of disease and whether the scarring process is stable or still active. Published studies have shown that the response to verapamil injections was similar in men regardless of the duration of the PD. With regard to the response to verapamil depending upon severity of curvature, this was also examined. The response rate was evaluated for mild (less than 30 degrees), moderate (30-60 degrees), or severe (greater than 60 degrees) deformity. The study showed that although there was a greater degree of curvature correction in men with moderate to severe curve, overall response rates were similar in all groups. The average degree of curvature correction which has been reported in studies on intralesional verapamil injection is in the 20 to 30 degree range. If a man has a 90-degree curve, it is not likely that he will experience more than a 30-degree improvement if he is a responder, which means he still has a fairly severe curve. Some men who have reduced their curve from 90 to 60 degrees, find that they can now function much better and do not require surgery For those who do require surgery, they may not need the more complex grafting procedure and may do well with the less risky plication operation.close

Dr. Levine answers: If you have severe PD which is compromising your sexual function and you have not responded to these topical or oral therapies, I would suggest that you speak to an authority in the treatment to Peyronie's disease. There is a list of suggested physicians who have some expertise in PD on this website. You should be aware that none of the oral or topical therapies have shown any significant benefit in clinical trials. Additional options you could consider include intralesional injections of verapamil or interferon, use of a penile external stretching device (FastSize), and of course the gold standard for correction of severe deformity is surgery.close

Dr. Levine answers: These are not symptoms of PD. A change in the sensation of the glans may be due to underlying medical problems such as diabetes which can affect the sensory nerves of the penis. Change in the color or pigmentation of the glans is usually more of a perceived problem, unless there are real lesions (ie ulcers, lumps) on the glans which should be examined by an urologist. I have seen men who have white spots, changes in color from purple to blue, white, and pink, which are within the realm of normal depending on blood flow. Glans color may be affected by external factors such as temperature and anxiety. The numbness of the testicles is another issue which I cannot explain, but may be due to the compression of the nerves in the perineal area. If you are an athlete who performs straddle sports such as bike riding this may affect these nerves. Lastly, your diminished penile rigidity may be an indication of erectile dysfunction and should be assessed by a urologist, this may be a vascular, neurogenic and/or psychogenic problem.close

Dr. Levine answers: This is a good question. For the man who develops acute onset of PD, the typical findings are pain in the penis, either followed by or preceded by the presence of a palpable nodule or lump, which is then followed by a shape deformity of the penis. Most commonly the deformity is curvature, but it can also be an indentation/narrowing or shortening of the shaft. Up to 90% of my patients also experience some diminished erectile rigidity. This may be due to underlying vascular or structural problems, but may also be due to psychogenic inhibition because of the distress caused by the change in the shape of the penis.close

Dr. Levine answers: Probably the best noninvasive test today is to have an evaluation by an urologist who is familiar with Peyronie's disease to determine whether there is evidence of a palpable plaque or scar in the tunica. To confirm whether this is PD, a surgical biopsy would be necessary, but this is invasive and very rarely indicated unless it is suspected that the lesion is not Peyronie's disease and could possibly be an unusual type of cancer of the penis known as fibrosarcoma. In my experience with thousands of patients with Peyronie's disease, I have only seen one case of fibrosarcoma, which did not present like a Peyronie's plaque. I have not recommended chronic low doses of Viagra as an anti-fibrotic agent except for men who also have erectile dysfunction. Research in the animal model of Peyronie's disease has demonstrated that all three of the PDE5 inhibitors (ie, Viagra, Levitra, Cialis) can reduce the scarring process when given to these experimental animals at the time of initiating the Peyronie's process. But, when the scar is already formed, the use of these agents did not result in significant benefit. Therefore I have been less enthusiastic to use these expensive medications without stronger evidence of benefit for established PD scars. On the other hand, I have used oral Trental and L-arginine for Peyronie's disease because of their presumed anti-fibrotic effects, relative low cost, and low side-effect profile. There is very little evidence showing any benefit in taking these drugs, but they do make some scientific sense.close

Dr. Levine answers: It is unlikely that the condom itself could trigger PD, but if during sexual activity there was trauma to the penis this is the more likely cause. Hourglass deformity is not typically an early onset type of deformity associated with Peyronie's disease. Usually there would be a small localized indentation which may progress to an hourglass deformity over time. In general, application of constriction bands, rubber bands, cock rings, are unlikely to activate the Peyronie's process by themselves particularly in the flaccid state.close

Dr. Levine answers: It is unlikely that Peyronie's disease has any direct effect upon ejaculation or upon your urinary flow. Premature ejaculation is a relatively common problem in adult men and should be addressed by your urologist. There are some unapproved medical therapies using SSRIs as well as sex therapy that may help this problem. With regard to the urinary flow issue, this may be due to several problems the most common is a urethral stricture or scar resulting in deviation of the urinary flow.close

The straightforward answer to this question is "yes." That is because it may be that the initial injury which occurred one year ago, may have not actually triggered the Peyronie's, but a subsequent silent injury may have finally set the stage to activate the abnormal scarring process. Up to 60% of the men I see in my practice are not aware of any injury that may have activated the Peyronie's disease. The other 40% note that following the injury there is a period of pain, a palpable lump, and then deformity. This can all happen very quickly as in a matter of weeks or it may take months to evolve. Unfortunately, there is no absolute standard presentation for the man with Peyronie's disease. This may reflect a variety of abnormalities which are happening within the body that ultimately presents with a scar and deformity which may be different in each individual.close

There have been 2 reports on young men with Peyronie's. These studies evaluated a large series of men and found that up to ten percent of those with Peyronie's disease are under the age of 40. Therefore, this process can present in men anytime from his teens to his 80s. The good news is that young men with Peyronie's tend to have good functional erections, in terms of rigidity and tend to respond well to medical therapy. Should they undergo surgery, they also tend to preserve their erections in the great majority of cases. Your bend of 45 degrees to the left is not severe but lateral curvatures tend to be more troublesome than upward (dorsal) curvatures. In fact, no treatment is necessary should the curvature not be causing you or your partner discomfort, but most men are uncomfortable seeing a curved penis and would like to have something done. As you have come to discover there is no known nonsurgical cure for Peyronie's disease particularly when the scar is stable. I have had virtually no success with any of the oral treatments and the topical remedies, potions, and cocktails that have been suggested on the internet, have not been studied adequately to encourage my recommendation. In time there will be clinical trials of collagenase which may make sense in your circumstance. Certainly injection therapy with verapamil or interferon is an option and there are ongoing studies with external penile stretching devices including the vacuum tube or the Fastsize penile extender. There are no outcome reports on these devices to share at this time. The oral treatments which I am currently using include pentoxifylline, which is a generic drug, but must be prescribed by a physician, and L-arginine, which is an over-the-counter amino acid. Both these agents theoretically reduce scar formation, but there is no published evidence in the scientific literature to support this. Lastly, although you were reluctant to proceed with surgery, it remains the most reliable and rapid way to correct deformity. With your degree of curvature, it is likely that a plication operation without removing the plaque, would be the least likely to cause compromise to your erection and has a very high rate of success with straightening. As always, consultation with an authority on Peyronie's disease would be most beneficial.close

Penile oxygenation is indeed crucial to maintain good vascular health within the penis. This is why we believe that men have nocturnal erectile activity. These erections occur due to a spontaneous reflex which happens anywhere from 2 to 7 times per night. This will in a sense "exercise" the penile vascular tissue by causing blood vessel dilation, better blood flow, and erection. This process nourishes the penile tissue and prevents collagen from forming. If collagen develops, this results in vascular tissue scarring with subsequent erectile dysfunction. This is the scenario that is believed to occur following penile nerve injury at the time of radical prostate removal for prostate cancer. In an effort to rehabilitate the penis following this surgery and to prevent erectile dysfunction, men are encouraged to take oral medication such as Viagra, Levitra, or Cialis at night to encourage nocturnal erections and/or to use drugs which are instilled into the urethra or injected directly into the penis to stimulate erection.close

At this point there is no recognized best treatment to prevent fibrosis from spreading within the tunica albuginea or into the vascular tissue of the penis for the man with PD. Recent research from California has suggested that increasing the amount of nitric oxide (NO) can act as an anti-scarring agent. The current medications that I use for Peyronie's patients to encourage an increased amount of nitric oxide in the penile vascular tissue include using such medications as Viagra, Levitra, or Cialis on a nightly to every other nightly basis, to encourage nocturnal erections and to increase nitric oxide in the penis as well as an over-the-counter amino acid known as L-arginine. L-arginine is the precursor to nitric oxide and there is some evidence that using this agent could possibly provide more nitric oxide to the penis.close

You clearly have an advanced problem with fibrotic disorders including the Peyronie's disease and Dupuytren's contracture. The PD is likely causing the loss of elasticity of the penis and subsequent loss of length and girth. It is also likely that the combination of diabetes, elevated blood pressure, and elevated cholesterol have injured your penile blood vessels resulting in ED. At this point there is no new therapy which might benefit your situation. It is my opinion when patients have a combination of both Peyronie's disease and advanced erectile dysfunction associated with underlining vascular disorders that a penile prosthesis should be placed. The deformity will be corrected during the operation with a maneuver known as "manual modeling." This is an outpatient surgical procedure, which has a very high rate of success allowing the patient, once he heals to engage in sexual activity with a straight and rigid penis. Needless to say, the 6-inch erection that you used to have is gone. If you want to know what the length of your penis will be with a prosthesis in place, grasp the glans (head) of the penis and pull it straight out from the body, this stretched length will approximate what you can obtain with a penile prosthesis. I would recommend a consultation with a urologist who is familiar with penile prosthesis implantation.close

Dr. Levine answers: This is an unusual presentation, but it does sound that your situation is consistent with Peyronie's disease. Peyronie's disease results in scarring of the jacket tissue of the penis known as the tunica albuginea. The scars which are also known as plaques are palpable just under the surface of the skin, most often on the top surface of the penis. They can pass through the middle of the penis, on the side or underneath as well. The scarring can occur in such a way as to not result in any deformity of the penis. If the lumps you describe are not in the tunica albuginea but are in fact within the skin or subcutaneous tissue of the penis, this may result in the visible lumps that you describe. This would not likely be Peyronie's disease. In my opinion, if you have no deformity and the lumps cause you no pain and are not growing, then no surgery is indicated. If it is Peyronie's disease and there is no deformity or pain, again no surgery is indicated. Overall, it may be best for you to have a second opinion regarding these lumps to better define the situation.close

There are rare penile cancers known as fibrosarcomas that can present with a thickened scar-like mass in the shaft of the penis. They tend to not involve the tunica jacket of the penis, but rather occur within the vascular tissue of the penis. Physical examination by a doctor can usually make the distinction. Fibrosarcomas tend to grow whereas Peyronie's plaques may expand but do not tend to grow into the spongy vascular tissue of the penis. In my experience, which is extensive in seeing patients with Peyronie's disease over the past 15 years, I have only encountered one fibrosarcoma and this was a patient who was sent to me from out of state for a very large mass within the penis that did not appear like Peyronie's disease. There are other types of cancers of the penis which may involve the urethra and may be felt along the under surface of the penis extending from the penile tip to the base of the penis. Either way, it is my advice that should you find a lump within the penis that you should have an evaluation either by your primary care physician, or better yet, a urologist.close

Dr. Levine answers:The scenario that you describe may be due to a diffuse scarring disorder involving the outer jacket of the penis, known as the tunica albuginea. Or it may involve the septum between the two erectile cylinders of the penis. Septal lesions are not so well appreciated and these scars involving the center portion of the penis are the ones that often times result in shortening and may interfere with blood flow beyond the area of the scar resulting in what is known as distal flaccidity or a softer shaft beyond the scar. Your question as to whether testosterone may be a factor is also important, but a low testosterone is rarely the cause of erectile insufficiency and tends to be associated with a low libido as well. It would be reasonable to see another physician, possibly one who has greater experience with Peyronie's disease or sexual dysfunction. Duplex ultrasound evaluation of the penis may reveal scarring within the tunica and/or septum as well as within the penile vascular tissue which may determine the cause of the problem. Typically the most common treatment for this type of problem, if the testosterone is normal, is to use a PDE5 inhibitor such as Viagra, Cialis or Levitra.close

Dr. Levine answers: No.close

Dr. Levine answers: This problem sounds more like primary erectile dysfunction, which may have a physical basis, but oftentimes could have a psychodynamic one as well. You might consider stopping masturbation and see if there is spontaneous recovery, but if not evaluation by an Urologist with a special interest in sexual dysfunction or a sex therapist would be in order.close

Dr. Levine answers: If you can obtain collagenase, which to my knowledge is not at all available, it would be absolutely contraindicated to place this agent on the skin as it could cause a significant injury in that area. Injectable collagenase, in time will hopefully be available in an upcoming multi-center study to determine whether it can result in a chemical breakdown of a Peyronie's plaque, but these studies have not begun.close

Dr. Levine answers: I am not familiar with Peyronie's disease causing any changes in CPK. This is usually due to muscle related injury, which is not considered a sequalae of Peyronie's disease.close

Dr. Levine answers: Peyronie's disease is a disorder of wound healing with unclear cause. Typically when it occurs, it will be associated with a lump, occasionally pain and deformity. Natural history studies have suggested that about 50% of men who come to see a physician will worsen with time, 40% will the stay the same and 10% will have spontaneous resolution of the deformity. If the deformity completely resolves with disappearance of the plaque scar tissue, it is unlikely that this was Peyronie's disease and probably just a slow healing wound within the penis.close

Dr. Levine answers: A 90-degree bend typically will result in significant compromise the ability to perform penetrative sex. It is also possible that it will put significant pressure within the vagina causing female discomfort. The development of yeast infections, I would not think is directly due to the Peyronie's disease, but more likely due to sexual activity itself. Your wife should certainly be evaluated by her gynecologist.close

Dr. Levine answers: Peyronie's disease is frequently associated with erectile dysfunction. Most of the time it will be a generalized reduction in rigidity, but sometimes it can be associated with what is known as "distal softening." This can involve the area beyond scar or just the glans. The mechanism is not clearly understood, but there is increasing evidence to suggest that there may be actual infiltration of scar tissue into the vascular tissue of the penis, which prevents filling in that area resulting in the distal softening. Further investigation in this field is ongoing. If your erections are suboptimal, use of a PDE-5 inhibitor would be in order.close

Dr. Levine answers: It is likely that the slight curvature that you see is a natural curve seen in many men. In fact, a curvature of less than 30 degrees in any direction is considered within the normal range, as it is not likely to interfere with sexual activity. Men who notice a lifelong history of curvature, which is severe enough to interfere with coitus, likely have a form of congenital deformity known as chordee. The only available treatment for this type of penile deformity is surgical straightening.close

Dr. Mulhall answers: In a recent study conducted by Dr. John Mulhall, more than 50% of men with Peyronie's disease had moderate to severe depression. This is supported by information collected in the APDA poll. Thus, your feelings are not uncommon. We recommend that you see a mental health professional to discuss these feelings. The good news is pain invariably goes away but may take a year to resolve. For men with severe pain, considering intralesional injection therapy in the hands of an experienced urologist may lead to more rapid improvement of the pain. vitamin E has never been shown to be of any significant benefit although most urologists prescribe it.close

Dr. Mulhall answers: No. Men with sensory problems in their penis need neurologic evaluation using tests such as somatosensory evoked potentials to define if there is a physical nerve injury.close

Dr. Mulhall answers: Not understanding the exact cause of the condition makes it very difficult to develop new treatments or a cure. However, at this point in time there are a number of centers in the world (mainly the USA) that are investigating the cause of Peyronie's disease. Indeed, there has never been a time previously when as much interest has existed in Peyronie's disease research. The single greatest barrier to curing Peyronie's disease is the lack of research money available to conduct excellent research. Through APDA it is hoped that the NIH or other organizations will look more favorably on this condition.close

Dr. Mulhall answers: The conventional wisdom has held that men with combined impotence (erectile dysfunction, or ED) and Peyronie's disease are ideally treated with a penile implant (a plastic device placed within the penis that can be inflated for sex and deflated after sex). This paradigm has more recently been challenged. Indeed, many men with ED can be well-treated using drug therapy such as pills (Viagra, Levitra, Cialis) or penile injections. If a man has curvature that is not severe enough to prevent him from being able to penetrate then it is possible to use one of the above drugs to help him regain his erection hardness. At the same time attention can be focused on treating the Peyronie's disease (pain, deformity etc). In cases where the deformity prevents penetration ability then the patient will need to consider surgical correction of the penile deformity. Correction of the deformity and erection problems can be accomplished most easily by placing a penile implant. However, there are patients who can consider other forms of penile reconstructive surgery to correct the deformity and straighten their penis who can also use pills or injections to help their erections. However, to date, there has not been a medical study comparing these approaches.close

Dr. Levine answers: It's true that you are currently in the active phase. Contemporary natural history studies have suggested that during the "active" phase, 50% of patients will have worsening of their deformity, around 40% will stay the same and less than 10% will have spontaneous resolution of curvature. Therefore, you are at risk to have progression of your Peyronie's, but given that it is so slight at this time, it may not progress. Avoiding vigorous gymnastics during sexual activity would be beneficial as well as avoiding female on top/ "rodeo sex" where the pressures on the penis can be quite substantial and may further activate the scarring process. It is reasonable to continue sexual activity, but just be careful. For men who have mild deformity and no significant pain but are interested in doing something short of injection therapy or iontophoresis, I have recommended the combination of pentoxifylline 400 mg two times a day which is a generic prescription drug, and L-arginine 500 mg two times per day. It is reasonable to continue on this treatment for three months. This therapy is best prescribed by a urologist who will provide an initial evaluation and then will be able to track your progress over time.close

Dr. Levine answers: This scenario appears to be one of a progressive Peyronie's disease where there is a loss of elasticity in the entire jacket tissue of the penis, known as the tunica albuginea. This tunic is the tissue which expands in girth and length during the normal erection and contains the vascular tissue as it fills with blood. If the jacket tissue has lost elasticity we can see a variety of deformities including curvature if only one side of the jacket is compromised or we can see generalized loss of length if there is widespread loss of elasticity. A loss of girth may occur as well. For the most part, the scarring process involves the tunic, but there is recent evidence that there may be even an invasion of the scarring process into the underlying vascular tissue which may compromise erectile rigidity as well. To determine the nature of your Peyronie's disease, usually a duplex ultrasound evaluation is performed to examine blood flow, the characteristics of the tunic and cavernosal tissue, whether there is calcification within the plaque, and to determine erectile response and curvature when the penis is erect.close

Dr. Levine answers: This is a complex situation that you describe and given your youth it is likely that your curvature is a congenital one, but may be due to a progressive scarring that may be associated with Peyronie's or just thickening due to the repetitive trauma. It is less likely that you have PD because you have no palpable plaque. A diminished intensity of orgasm is not unusual in the older man, which appears to be a natural change that occurs with aging, but in the young man this problem may be due to underlying neurological deficits but most commonly it is a psychodynamic problem. Unfortunately, once a man starts having sexual dysfunction the attention to that problem becomes intensified and this can result in further reduction or inhibition of one's sexual response. The best treatment for this may be seeing a local sex therapist who may be able to help identify the triggers which inhibit your sexual response and may then result in an improved overall experience with time. It is also reasonable to have your testosterone checked as this can be associated with reduced libido and ejaculate volume.close

Dr. Levine answers: This may be a very mild form of Peyronie's disease and is quite common for the plaque or nodular scar to seem as though it is moving. Basically this is part of the abnormal scarring process that occurs within the jacket tissues of the penis. The good news is that your deformity is "slight." You should be careful to avoid sexual activity which will put extraordinary stress forces on the penis; this may activate the disease further.close

Dr. Mulhall answers: The plaque that occurs with Peyronie's disease is a scar and scars contract, so all men with Peyronie's disease have some degree of contraction of their penis in both the flaccid and erect state so loss of penile length and stretchability is common. The vein and color changes are not due to the Peyronie's disease itself although some men complain of them. Men with Peyronie's disease often (understandably) become very focused on their penile appearance and start a regimen of daily inspection of their penis, which leads to frequent complaints about features that are naturally present on the penis.close

Dr. Levine answers: It is unclear as to whether you have developed Peyronie's disease or some other type of scarring within the penis causing the deformity. This is certainly something that should be evaluated by a urologist with an interest in sexual dysfunction, as if Peyronie's disease is discovered, it may be worthy of some form of nonsurgical treatment.close

Dr. Levine answers: Erectile dysfunction is commonly found with Peyronie's disease. In fact in my own practice, 90% of the men with Peyronie's disease have reported diminished erections. Fifty percent of the time this occurs before the Peyronie's disease occurs and the other 50% occurs after onset of Peyronie's disease deformity. Evaluation to date has suggested that the erectile dysfunction is likely due to the same causes as erectile dysfunction in men without Peyronie's disease. That is vascular insufficiency. Most of the time it is an arterial insufficiency, sometimes it is a venous insufficiency or mixed problem. Erectile dysfunction can also occur as a result of psychogenic inhibition, which is also associated with Peyronie's due to the devastating psychological effects of this disorder. If the erections were found to be suboptimal for sex, then a PDE-5 inhibitor medication such as Viagra, Levitra or Cialis are reasonable treatments with a low risk of making the Peyronie's recur or worse. Peyronie's disease usually has an acute progressive course and then stabilizes, but rarely completely resolves. I have seen a few men who have had multiple episodes of Peyronie's over their life. Therefore for the great majority of men once it stabilizes it does not recur.close

Dr. Levine answers: ]It is unusual to have the pain associated with Peyronie's last as long as 16 months. It is possible that he has significant tethering of nerves in the scar tissue, which are stretched at the time of orgasm and ejaculation. It is also possible that if the pain is occurring just with ejaculation that there may be another cause to his pain. Therefore I recommend evaluation by a urologist who is specifically interested in sexual dysfunction.close

Dr. Levine answers: Peyronie's disease is manifest in the early phase with pain, which can be present in the flaccid state when touching the penis, or especially when erect or trying to have intercourse. Typically the pain will diminish with time. The pain and the deformity can result in psychological distress, which can interfere with your erection, but there may also be vascular changes, which may contribute to this as well. It is unlikely that if you try to stimulate your penis without putting excessive stretching forces on the penis that you will worsen the Peyronie's disease. Sexual positions, which might cause excessive stretching forces, could reactivate or aggravate the acute inflammatory process, which would result in pain and possibly progressive deformity. Published reports have suggested that use of a PDE-5 inhibitor such as Viagra, Levitra or Cialis may enhance the erection. There is some research in the animal model of Peyronie's disease, which has suggested that this class of drugs may actually stop the scarring process.close

Dr. Levine answers: This is an excellent question, as you point out some of the misconceptions for the use of Viagra or the other PDE5 inhibitors (i.e. Cialis and Levitra). All three of the companies who make these drugs have in their package insert a cautionary note regarding using these drugs in men with ED and Peyronie's disease. This is because the companies did not study ED in men with Peyronie's disease and therefore they cannot make any claims to the FDA resulting in the cautionary note. On the other hand, a published study examining the effects of Viagra in men with ED and PD demonstrated that it did improve erectile function in 71% of the men receiving the Viagra. In addition, none of them had worsening of their deformity or new onset of pain. Furthermore, there is very recent research evidence that Viagra, as well as the others, can increase the amount of circulating nitric oxide (NO) which appears in the research setting to have an anti-fibrotic effect. The key point to remember is that if you use Viagra or the other agents to enhance your erections in the presence of Peyronie's disease it is possible that you could reinjure the penis during sex. It is therefore wise to be careful about one's sexual activity so as to reduce the likelihood recurrent trauma and reactivation of the Peyronie's process. So far this has not been a problem for my patients.close

It is extremely unlikely that TURP is associated with PD. Given the number of TURPs that have been performed at least historically, we should have seen a signal of a link. Furthermore, in my patients who link the two together than man has a dorsal plaque which in no way could be related to the surgery per-urethram.close

Peyronie's disease is a disorder of wound healing which often times will present with pain because of inflammation associated with the initial scarring process. The inflammation irritates the pain fibers which are typically activated when the penis becomes erect causing stretching of these nerve fibers. When the pain is present, it usually will resolve within weeks to months, although I have seen patients who have persistent pain up to 1-2 years. Persistent pain for 2-5 years as noted in these questions may suggest that the pain is due to a torque-effect. This means that when the penis becomes fully erect it puts a great deal of pressure on the scar resulting in a discomfort which is different than the inflammatory pain associated with acute or new onset Peyronie's disease. For men who have persistent pain, I advise the use of anti-inflammatories such as ibuprofen or Meloxicam, a prescription drug. Pain may also be treatable with intralesional injections of verapamil or interferon. Over the counter remedies have not been shown to be beneficial for Peyronie's disease at any stage. For the man who has persistent problems associated with Peyronie's disease, it makes good sense to see a recognized expert in this field to address any other potential causes to the pain.close

Peyronie's disease is a disorder of wound healing which often times will present with pain because of inflammation associated with the initial scarring process. The inflammation irritates the pain fibers which are typically activated when the penis becomes erect causing stretching of these nerve fibers. When the pain is present, it usually will resolve within weeks to months, although I have seen patients who have persistent pain up to 1-2 years. Persistent pain for 2-5 years as noted in these questions may suggest that the pain is due to a torque-effect. This means that when the penis becomes fully erect it puts a great deal of pressure on the scar resulting in a discomfort which is different than the inflammatory pain associated with acute or new onset Peyronie's disease. For men who have persistent pain, I advise the use of anti-inflammatories such as ibuprofen or Meloxicam, a prescription drug. Pain may also be treatable with intralesional injections of verapamil or interferon. Over the counter remedies have not been shown to be beneficial for Peyronie's disease at any stage. For the man who has persistent problems associated with Peyronie's disease, it makes good sense to see a recognized expert in this field to address any other potential causes to the pain.close

A flexible sigmoidoscopy is performed for evaluation of the rectum and lower sigmoid colon. This procedure, to my knowledge, has not been associated with triggering Peyronie's disease as there is no direct trauma to the penis or the genitalia. Certainly, it is possible that any trauma in the pelvic area may activate Peyronie's disease as is seen in patients following radical prostatectomy where up to 10% of men will develop Peyronie's disease following this surgery where there is no direct trauma to the genitalia. It is my opinion that in the latter circumstance, there may be some release of proteins which can activate the scarring process in the penis. Therefore, if we take the same scenario, it may be that trauma in the rectal area may activate release of such proteins and in the genetically susceptible individual, Peyronie's disease could be activated. This is all theoretical, of course, and at this point, one could not place blame for developing Peyronie's disease on the surgeon performing radical prostatectomy or the physician performing colonoscopy.close

This is an interesting question as the chronic pelvic pain disorders such as prostatitis and interstitial cystitis and possibly chronic orchialgia (testicular pain) appear to be linked to the concept of chronic pain where there is a central nervous system modification of nerve response. These are pain syndromes though, and Peyronie's disease appears to be more of a wound healing disorder which is associated with early pain during the acute phase. At this point, my own experience does not suggest that there is a correlation between Peyronie's disease and a history of prostatitis, interstitial cystitis, or epididymitis. I am not aware of any reported association between these diseases in the literature.close

Absolutely, tobacco use around the time of surgery will increase the risk of complications and may impede proper healing because of reduced blood flow. Tobacco intake in any form will cause blood vessels to constrict after acute use, but with chronic exposure tobacco will accelerate the aging process of blood vessels making them less likely to dilate in response to internal stimuli.close

Several studies have shown that 10% of the men presenting with PD are under 40 years old. Younger men with PD have also been shown to do well with non-surgical treatment presumably because the healing response is better in younger men. However, most men under 20 who present with penile deformity have a congenital (born with it) type of problem also known as chordee. So far, the only successful treatment for chordee is surgical straightening with some type of plication/Nesbit procedure.close

There is no connection between sterilization and PD. If the deformity is so bad that it prevents vaginal penetration, conception will be compromised, but this does not make the man sterile.close

Dr. Levine answers: It is unlikely that any type of urethral manipulation would trigger Peyronie's disease unless it resulted in a downward or ventral bend of the penis. This would suggest that urethral trauma may have activated some inflammation and scarring on the undersurface of the penis causing the downward curve. Most men who present with Peyronie's disease have either an upward or lateral curve, which may have been triggered by other silent trauma. Therefore it is highly unlikely that this was due to any type of urethral manipulation including cystoscopy.close

Dr. Levine answers: At this point there is no evidence of direct association with the use of any medication and Peyronie's disease. Historically, articles suggested in association with various medications, but these were typically case reports and due to a lack of understanding of the disease process. Many men are using a variety of antidepressants at this time, and yet there does not appear to be an increased occurrence of Peyronie's disease in men using these medications.close

Dr. Levine answers: Any type of injury that occurs to the erect penis could activate Peyronie's disease in the susceptible individual. This would include masturbation or penetrative sex. This would be most apt to occur if the penis had excessive pressures being placed on it such that it bent excessively in one direction or another, in which case a microtrauma within the tunica albuginea could occur, and therefore activate the abnormal wound healing process associated with Peyronie's disease.close

Dr. Mulhall answers: Many experts believe that there is some genetic and/or immunological facet to Peyronie's disease. How else could we account for why some men get the condition and others do not? As with much else in Peyronie's disease, there has been no real study of the association between immune conditions and Peyronie's disease. However, there have been no reports of Peyronie's disease rates being higher in men with such disorders. With appropriate funding such research would be possible.close

Dr. Mulhall answers: The penises affect by Peyronie's disease present with variety of deformities. The type of deformity that an individual patient experiences depends on 3 major factors (1) the size of the plaque (2) the location of the plaque and (3) the elasticity of the tunica that is unaffected by the plaque. Similar volume plaques in different locations may result in different deformities especially if the tunical stretchability is different between 2 men. Similar locations may result in different deformities if the plaque volume or tunical elasticity is different. Most men have curvature as the plaque is located on one side of the penis; upward curvature when the plaque is on the upper (dorsal) side of the penis for example. If the plaque is one side, let's say the dorsum and starts to extend around from the midline to the sides of the penile shaft, then a man may notice indentations on either side of the penis which may eventually be severe enough to cause waisting. Waisting on both sides is called an hourglass deformity and the result of this is a hinge-effect or instability during sex. Some men present with waisting without curvature and this may result from a plaque that is located on the side of the penis and not the top or bottom.close

Dr. Levine answers: Any traumatic event to the penis could possibly activate Peyronie's disease in the susceptible individual. It is not exactly clear to me where your piercing is located on the penis, but usually it is in the area of the urethral opening of the penis which is well out of the area where Peyronie's disease occurs. Therefore, it is more likely that you had a separate, maybe silent injury to the penis most during intercourse that activated this process and therefore I think it is more likely coincidental and not due to the piercing.close

Dr. Levine answers: The typical injury occurring with biking or any straddle sport is an injury to the vascular or nerve supply to the penis which can result in erectile dysfunction and/or a numb penis. The fact that there is pain may indicate a nerve entrapment. If the deformity of the penis is new, there may also be scarring of the penile tissues resulting in the curvature. It appears that there may be both an erectile dysfunction problem here, which may be due to nerve and/or vessel injury, as well as a possible Peyronie's problem. Clearly, the best advice here is to see a local urologist for proper evaluation.close

Dr. Levine answers: It appears that the most common cause for triggering Peyronie's disease is local trauma to the penis, which most commonly occurs during sexual activity when the penis is erect, but a man may develop Peyronie's disease following a direct trauma to the penis that can occur from a kick, motor vehicle accident or a variety of other situations. Regardless if the individual is susceptible to Peyronie's disease, the trauma may trigger the abnormal wound healing process, which ultimately results in the Peyronie's plaque.close

Dr. Mulhall answers: There exists no evidence that urethral catheterization causes Peyronie's disease. Indeed, as you point out the "injury" would be remote from where the vast majority of the plaques are located. It is likely that the trauma that is implicated in Peyronie's disease development is far more subtle in most men than that which may occur with urethral catheterization. Remember there are millions of men every year who are catheterized for a variety of reasons and thousands who live their lives with a catheter in place permanently and yet they appear to have no higher incidence of Peyronie's disease than the general population.close

Dr. Mulhall answers: This is an excellent and frequently asked question. There is no indication that ILV causes more trauma and the evidence for this is that many men have stabilization or improvement of the Peyronie's disease when they have used ILV. Likewise, there is no evidence to suggest that older men who do ILV do more poorly than younger men. Exactly how ILV changes the biology of the plaque is unclear and much research needs to be done to explore this. Of note the kind of trauma that results in Peyronie's disease is most probably excessive torqueing of the penis and not penetrating trauma as occurs with the sue of a needle penetrating the plaque.close

Dr. Levine answers: Stress can certainly be a contributing factor to many disorders. It is unlikely to activate the Peyronie's process directly, but stress may result in diminished rigidity which may subject the "at risk" penis to a greater likelihood of injury which would then activate the Peyronie's process. As medicine matures and we know more about the psychodynamic aspects of stress it may be that we would find that anxiety and stress may actually have physiological responses which can activate the scarring process. At this time, it is more likely to be coincidental or due to a traumatic event that happened with a less rigid erection during your stressful period.close

Dr. Levine answers: Hypertension has been associated with erectile dysfunction as it causes progressive injury to the blood vessels within the penis reducing the ability of those vessels to dilate in response to a sexual stimulus. Men who have compromised erections and who are also susceptible to Peyronie's disease may injure their penis while trying to have intercourse with a soft erection. It may be that the buckling that occurs with a less rigid penis results in intratunical micro-trauma, which could activate the Peyronie's process in the susceptible individual. One could think of this type of injury much like a metal fatigue fracture that happens from bending a piece of soft metal back and forth on multiple occasions until the metal fractures.close

Dr. Levine answers: This is an interesting question, as up to 30% of men with Peyronie's disease also have Dupuytren's contracture. It may be that there is a similar genetic process here resulting in a site specific scarring in the hand and in the penis. You might talk to other male family members to determine whether they have evidence of Peyronie's or DC.close

Dr. Levine answers: It is unlikely that the cystoscopy triggered this problem at all, but because you have Dupuytren's contracture, you may have a higher genetic predisposition to develop Peyronie's disease.close

Dr. Mulhall answers: Both Peyronie's disease and Dupuytren's contracture are known as fibromatoses, condition in which there is excessive scar formation (just as keloid scars are also in this group of disorders). The literature would suggest that the incidence of Dupuytren's contracture is higher in men with Peyronie's disease than in the men without Peyronie's disease. In my practice approximately 4% of men with Peyronie's disease have Dupuytren's contracture. Dupuytren's contracture is a scarring of the tendon sheaths in the hand typically affecting the fourth and fifth fingers. There are some experts who believe that to get Peyronie's disease and probably to get Dupuytren's contracture a man needs to have a certain genetic make-up and this may be the link between the two conditions.close

Dr. Levine answers: There is no known evidence that the use of PDE-5 inhibitor drugs including Viagra, Cialis or Levitra causes Peyronie's disease. The package insert on all of these agents states that the use of these drugs should be "with caution", as the Peyronie's disease patient population was not studied during the clinical trials by the drug manufacturers. In the International Journal of impotence Research there is published a report on an open label study using Viagra for men who had Peyronie's disease and erectile dysfunction (Levine & Latchamsetty IJIR, 14, 478-482, 2002)). This study was conducted to reduce the anxiety about the use of these agents in men with PD and ED, and demonstrated a 70% erectile response rate (similar to other studies with these agents), and no worsening of Peyronie's disease or any new pain. The primary concern is that in men who get a better quality erection, whether it is with the PDE-5 inhibitors, injection therapy, MUSE or vacuum device, that all of these may create a situation which may make the patient who is susceptible to Peyronie's disease, more apt to injure the penis during intercourse because of the firmer erection. Recent animal model studies of PD have suggested that elevating nitric oxide in penile tissue specifically with Viagra and Levitra may reduce the scar formation associated with Peyronie's disease. At this point, as there is no convincing evidence that use of these medications will prevent or reduce progression of Peyronie's disease, therefore the routine use of these medications as a remedy for PD cannot be recommend.close

Dr. Mulhall answers: There is no convincing evidence that any medication (including the 3 mentioned in this question) is associated with the onset of Peyronie's disease. Any medication that would be associated with Peyronie's disease would either have be associated with a medical condition that was linked to Peyronie's disease or itself would have to cause some alterations in the tunica albuginea and predispose the patient to this condition. Medications used in men with hypertension, diabetes may seem to be associated with Peyronie's disease but in fact it is more likely that the underlying medical conditions are the root link. There has been a suggestion for example that beta-blockers (used for hypertension) may be associated with Peyronie's disease but I would contend that the medical condition is the link and not the medication.close

Dr. Levine answers: Intralesional verapamil remains as the most commonly used injection approach for Peyronie's disease and appears to have fairly consistent results with respect to response. Overall, between 50-60% of men who complete a course of intralesional verapamil will have measured improvement of curvature. "Measured improvement" does not mean a cure, but does indicate a reduction of curvature measured to be at least 10 degrees. Improvement has been measured to be as much as 70 degrees. The current 3-arm approach to non-surgical of Peyronie's disease is to use pentoxyphilline and L-arginine orally, intralesional verapamil injections every 2 weeks and daily traction therapy (or more daily). This combination has been shown in an ongoing study to result in a more robust and earlier response than with verapamil alone. As to the age of the patient, it is unusual to have men under the age of 40 with Peyronie's disease, but still 10% of men with Peyronie's disease are under the age of 40 and appear to respond well to non-surgical therapy as well as surgery. The experience with Iontophoresis is limited and it is my personal opinion that Iontophoresis offers little benefit other than reduction of pain and mild curvature improvement. Although there have been no studies using iontophoresis with traction, I would certainly recommend this combination approach if iontophoresis is used.close

Dr. Levine answers: This question addresses many issues in Peyronie's disease, first that Peyronie's disease can present with a variety of deformities anywhere along the shaft of the penis and there is nothing particularly unique with respect to treatment response about the curvatures which occur at the base, middle or distal shaft. There is also little evidence that spontaneous correction of a Peyronie's disease plaque occurs. In fact, the most recent natural history studies show no more than 10% of men will have spontaneous improvement (not complete resolution) and that within the first 6 months to one year after the disease shows itself, 50% of men will get worse if no treatment is offered. With regard to oral therapy, there is no published controlled trial of oral medications, which has been shown to provide any meaningful benefit with regard to penile deformity. Pentoxyphilline, and L-arginine, as well as the PDE5 inhibitors, have been shown in animal model studies to reduce the production of scar. Reports on these agents have not been published on humans. At this time these penile agents have not shown to reverse scarring other than occasional anecdotal reports.close

Dr. Mulhall answers: Firstly, at 5 years the likelihood of your PD worsening is practically zero unless you re-injure your penis. There is no good evidence that Pentox is of significant benefit, although many experts use it because of some experimental (nonhuman) evidence that it has a beneficial effects on PD cells. In speaking with Dr. Tom Lue who introduced this idea, he uses it now for men with calcified plaques to reduce calcium in the plaque. I have stopped using Pentox except for the latter patients. Pentox is a safe medication and will not have an effect on your immune system. There is no data that vitamin D in combination is of any greater benefit.close

Dr. Mulhall answers: It is important for readers of this site to understand that I have no association or financial involvement with FastSize. To summarize the role of traction therapy for PD, firstly there exists some experimental evidence that chronic stretching of scars softens the scar and may result in better function (in the case of the penis, this would mean curvature improvement and length gain). Saying that, to date there is only one small study published demonstrating benefit to the traction device (Levine) while the other demonstrated little benefit (Gontero). It must be said that at his time it is unclear if traction therapy is worth the effort or not. What I tell my patients is that in 2 years we will likely have better, more definitive data, and this may be good or bad news. However, until such time as we have definitive data I recommend my patients consider using the device, but I cannot be 100% certain what the outcome is going to be. Dr. Levine has an ongoing study suggesting there is a benefit to adding traction therapy to intralesional injections and I await the publication of this data. Studying the effect of traction therapy is complicated and the different results between Levine and Gontero's studies may be multifactorial.close

Dr. Levine answers: As you know, erectile dysfunction (ED) frequently accompanies Peyronie's disease and in fact up to 90% of patients have been reported some reduction of rigidity. The use of all three of the PDE-5 inhibitors (i.e. Viagra, Levitra, and Cialis) have been used successfully to improve rigidity in Peyronie's disease patients. It should be recognized though that a much stronger erection with curvature may have a greater risk of being reinjured during sex and make the deformity worse. But this has not been reported. The use of the L-arginine is as an anti-fibrotic (i.e. anti-scarring) agent. It should be taken daily and the recommended dose is 1000 mg twice per day. Viagra, Levitra, and Cialis are taken on an as-needed basis, but can be taken up to once per day. There is experimental evidence to suggest that Viagra as well as the other two PDE-5 inhibitors can have some anti-scarring effects as well, but these have not been demonstrated in proper trials.close

Dr. Levine answers: I am not familiar with Peyrontin and in general there have been no placebo controlled trials that have shown a benefit to using any oral agent over taking a placebo pill. This includes vitamin E, Potaba (other than reducing the plaque size), colchicine, tamoxifen, and carnitine. At this point the only oral agents which are recommended by some experts are L-arginine, 1000mg 2x/day, and pentoxfylline, 400 mg 3x/day. These are offered as they have been shown in the experimental animal model of Peyronie's to have an anti-scarring effect particularly when the scar is just beginning to form. There is still no evidence that these agents have any significant beneficial effect on penile deformity and scarring in men with Peyronie's.close

Dr. Mulhall answers: As a scientist who has devoted more than a decade to the laboratory and clinical research in men with PD, I am very comfortable stating that there is no data that jelqing is of ANY benefit to men with PD. Indeed, I have seen a number of men who have clearly injured their penis by using this technique. Yes, there are posts and blogs swearing that this technique has resulted in improvement. As a physician who sees 20 PD patients per week I will tell you that it is common for men to see one of my patients who swears his curvature has improved but when curvature evaluation is conducted there is no improvement or there is even worsening. I can only presume that there is a significant "wishful thinking" component to this phenomenon.close

Firstly, there is no convincing evidence that any dose of L-arginine is of any benefit for the stabilization or reversal of PD associated penile curvature. Saying that, it is a very safe agent so high doses as outlined by the other clinician is likely to cause you no significant side effects. Occasionally, patients complain of facial flushing with high dose L-arginine.close

Vitamin E is one of the first oral agents used for the treatment of PD. However, there is no convincing evidence that alone or in combination with other agents it is of any significant benefit. Its use advocated by generations of urologists without any real understanding of the medical literature. Recently, in older men and men with heart disease, vitamin E has been shown to worsened cardiac health. It is likely that vitamin E is a placebo and has not real benefit. Stem cell research is a hot topic at the moment and it is only a matter of time before it will be used for PD. There are no studies ongoing at this time.close

Firstly, how we should be treating men in your stage of the condition is unknown. Any advice you receive from a PD expert is based on personal opinion and not on real evidence. There is experimental evidence that pentoxifylline and Viagra may do "good things" to PD cells in a petri dish. However, at this time there is no evidence from human studies. There is human data on carnitine but no convincing evidence that alone or in combination it is of any significant benefit. Saying that all three agents are safe and likely you will experience no significant side effects. Viagra especially is totally safe for daily use.close

By and large if the calcification is extensive, and involves virtually the entire plaque in the area of the deformity, then any intralesional injection approach does not work as these drugs have no effect upon bone. Furthermore the needle is unlikely to pierce the calcification. On the other hand, when there is stippled or scattered calcification in the plaque there has been some reported success with intralesional verapamil injections, particularly when this is combined with traction therapy using the Fast Size device. There is also evidence that patients who have a calcified plaque associated with painful erections that when injections of verapamil are used around the edges of the plaque that this may accelerate stabilization of the plaque, and reduce the pain.close

This is a good question and in fact Dr. Levine has had direct contact with the physician in Florida who has championed this approach. Unfortunately the situation is different in Peyronie's disease in that with Dupuytren's the scar tissue attaches to the underlying tissue causing the tethered finger which can not fully extend. By using the percutaneous technique the attachment can be severed, thereby correcting the finger deformity. Unfortunately, there is no such attachment of the plaque to underlying tissues which when released would correct the deformity. Current surgical technique for PD uses a variety of plication procedures or making releasing incisions through the scar, but this leaves a defect/gap in the tunica albuginea which needs to be filled with a graft. Dr. Gerald Brock in London, Ontario has used a trans-tunical subtotal incision of the plaque but typically a plication procedure is necessary as well to get complete correction of deformity.close

Lasers have been used as a topical application with no evidence of benefit. Lasers have been used during surgery to vaporize or cut the plaque out. Published reports on this have demonstrated no correction of deformity and in fact patients have been made worse. At this point lasers are not recommended as treatment for Peyronie's disease at all.close

No, verapamil injections can certainly begin without an ultrasound, but an ultrasound does provide information as to whether there is extensive calcification in the plaque. A large sheet of bone will make intralesional injection of any drug result in little benefit as the needle cannot penetrate the calcification. Before initiating any form of treatment in my patients, I perform a penile duplex ultrasound using intracavernosal injection. This test provides significant information regarding penile blood flow, presence of calcification, erect deformity which can be measured with a protractor as well as girth assessment. All of this information can be useful in terms of offering subsequent treatment.close

This is a good question as it pertains to recent research. A pilot study was completed in Chicago examining the effects of penile traction therapy with the FastSize penile extender (FastSize.com). This study which required men to use the device for a minimum of 2-8 hours per day for six months, showed that in all of these men there was measured improvement of curvature from 10-45 degrees, enhanced length from 0.5-2 cm, and all of those men who had some indentation, hourglass deformity or hinge effect had improvement or complete resolution of that deformity. This is very exciting information from a small study and should warrant further investigation with larger scale trials. What is also important about this study is that there were no adverse events including no skin lesions, ulcerations, change in sensation, erectile dysfunction or worsening of Peyronie's disease. In the meantime I have initiated the use of the FastSize penile extender as treatment for Peyronie's disease in my patients, typically in concert with oral treatment using Pentoxifylline and L-arginine and intralesional verapamil injections. There are other devices currently on the market, primarily in Europe, with which there have been some initial studies showing benefit, in particular following surgery for Peyronie's disease to prevent shortening.close

The vacuum pump is a plastic cylinder into which the penis is placed and a seal is created at the base of the penis. At the far end of the cylinder there is a pump which can be manually or battery-operated. By activating the pump, blood is pulled into the penis by a vacuum. As the penis becomes engorged it will stretch the tunica. It is felt that prolonged stretching of the tunica with the vacuum may result in remodeling of the scar tissue within the tunica and thereby result in some straightening. To date there are only anecdotal reports and no formal studies have been done, although there are plans to initiate such a trial. My initial studies using verapamil injections with or without the addition of vacuum therapy used once to twice per day for up to thirty minutes per treatment did not show any substantial benefit in the men who used the vacuum. I do believe that a more formal, multi-center trial will give us further answers as to whether vacuum therapy will benefit the man with Peyronie's. For those men with Peyronie's disease who have used the vacuum device as therapy, there have not been reports of substantial benefit, and it appears that the vacuum device will not worsen their Peyronie's disease. Clearly, this is something that needs to be managed properly to prevent inadvertent injury. Most importantly, the device should not be left on the penis for longer than 30 minutes as this can result in a low blood flow state which could cause injury to the internal tissues. These devices are now available over-the-counter at many pharmacies and typically cost less than $200. A more professional model is available by prescription from physicians around the country. These devices cost up to $400 for the manual device and $550 for the battery operated device. Many insurance companies will cover a use of the prescription type vacuum devices, especially if they are being used for the treatment of erectile dysfunction.close

Transdermal verapamil has been available for many years now, but unfortunately there are no published studies which have demonstrated that this preparation of verapamil results in penetration of the drug down into the diseased tunica albuginea. In fact, one study showed that there was no penetration at all in a series of men who were exposed to the drug. A recently published study looked at three different types of transdermal application for PD including transdermal verapamil. This report suggested that the verapamil gel resulted in marked improvement over the other two. Unfortunately, it was not a well-conducted study and therefore is at this time not a treatment that I would recommend to any of my patients.close

Your question is unclear. If indeed you have Peyronie's disease and it resolved, and the acute, painful phase resolved, but there is residual curvature, then indeed traction therapy can be used. Traction therapy may be best employed early in the development of Peyronie's, but if it occurs when the disease is quite active and painful, traction may not be tolerated. In my limited experience, it did appear that men with Peyronie's disease of any duration did experience some benefit following use of traction therapy including increased length, reduction of curvature, and even some girth enhancement in areas of narrowing or indentation. The key to success with traction therapy is daily use for a minimum of 2, but better 4-6 hours per day for 6 months.close

Dr. Levine answers: Dr. Egydios is an expert in the surgical correction of Peyronie's disease from Sao Paulo, Brazil. He has developed a technique of surgical correction using "geometric principles" to define the size and shape of the graft necessary to correct the deformity. Certainly for the urologist who has limited experience performing graft repairs for men with Peyronie's disease this may be a useful technique to learn. For those surgeons who have been performing these procedures for many years; they have developed techniques of their own which have yielded similar results to those of Dr. Egydio's.close

Dr. Hellstrom answers: Initial management of the acute presentation of PD is conservative and non-surgical. Although there are numerous surgical options for the correction of PD, the choice of an initial treatment to choose is somewhat of a dilemma. It is recognized that 10-15% of acute PD will resolve naturally over the first year. Forty percent will stay the same, and 45% will get worse. For this reason most clinicians are inclined to prescribe medication. Oral treatment alternatives include; vitamin E, potassium aminobenzoate (Potaba), colchicine, tamoxifen, and L-carnitine. Most studies on oral therapies involve small numbers of patients with poor follow-up, lack of control or placebo groups, and poor objective parameters to measure improvement. None of them can be strongly recommended, despite their popularity. On the other hand, intralesional injections with various agents such as calcium channel blockers, clostridial collegenase, and interferons have also been used as minimally invasive treatment options for PD. Studies using interferon and verapamil injections are promising and may provide improvement and/or stabilization of the deformity. This makes injection therapy a reasonable option for patients with early-onset PD. Surgery for PD is contemplated only after stabilization of the disease process, which occurs after about 1 year and is generally reserved for men with severe penile deformities that impede satisfactory sexual intercourse.close

Dr. Mulhall answers: Most urologists are driven by results (physicians often use the terms data or outcomes) and safety in deciding what to do for patients. The absence of data demonstrating that VED is of benefit for Peyronie's disease patients has resulted in much of the disinterest among urologists for using this strategy. Furthermore, it is recognized that the use of the VED (particularly non-FDA approved devices such as can be bought "over-the-counter") by men without Peyronie's disease can result in the development of Peyronie's disease. Therefore at this time VED therapy is not on the list of recognized treatments for Peyronie's disease. Of course there are anecdotal reports (word of mouth but not in the medical literature) of men seeing improvement in their curvature using VED. There are 2 potential reasons for this. The first is that the VED minimizes the degree of curvature because of the blood engorgement of the subcutaneous tissues with the use of the vacuum. So when the penis is in the VED chamber and the device is activated a man who really has 45 degrees of curvature may look as if he has only 30 degrees. This is an artificial "improvement" which is not present when he has a natural erection. The other reason why some men "swear" by the VED is that as previously mentioned some men with Peyronie's disease improve over time without any treatment at all. It is entirely possible that some of the men who "responded" to VED therapy may in fact have been those who would have improved anyway. Until such time as there is a well conducted study assessing the VED in this patient population, it is unlikely to assume a significant role in the treatment of men with Peyronie's disease.close

Dr. Mulhall answers: This question can be answered by reading the answer to the question on VED. There is no evidence that exercises is of benefit. Might it hurt? I think that such exercises are not likely to hurt the penis if performed in the flaccid (soft) state. However, if performed with the penis erect, there is a possibility that a secondary plaque may develop. It is unlikely that any studies will ever be performed looking at controlled trauma (stretching etc) to the penis of men with Peyronie's disease.close

Dr. Mulhall answers: There is great debate about this, but most authorities would recommend that the man use some form of treatment in an attempt to prevent progression. As mentioned in response to other questions, there is no data that transdermal therapies are of any benefit so they are not used in my practice. ESWT has no safety data and has mixed success rates to date, so this is not offered to patients. The mainstays of treatment in my practice are intralesional verapamil (ILV) and oral colchicines. The latter is typically reserved for men who do not wish to try ILV or are not candidates for this (such as men with certain cardiac conditions and men with ventral plaques). In my practice only 12% of men over the first 12 months get better without any treatment. This figure varies from practice to practice depending how closely men are monitored and how curvature is measured. As mentioned in in Dr. Mulhall’s article on How to Choose a Physician for Peyronie’s Disease if you are told that nothing can be done and that you should return in 6 months without discussing any treatment then you may need to consider a second opinion.close

Dr. Levine answers: I am aware of no studies using acupuncture for the treatment of Peyronie's disease. It is certainly possible that acupuncture may reduce the pain associated with Peyronie's disease as it has been found to be a successful treatment for a variety of pain syndromes. With regard to any improvement of penile deformity I can think of no mechanism where this would work, but stranger things have been reported. I for one would not be recommending acupuncture for improvement of penile deformity associated with Peyronie's disease.close

Dr. Levine answers: Unfortunately there is little evidence that any of the pills, potions and patches which are advertised on the internet provide any benefit whatsoever, with regard to enhancement of penile girth or length. Nor are they expected to have any potential benefit in terms of treating penile deformities associated with Peyronie's disease. I am aware that the federal government is investigating several companies for making false claims regarding sexual and penile enhancement. Unfortunately because the advertised agents are not submitted for FDA (Federal Drug Administration) approval, the regulations to control them are not under the control of the FDA, but rather under the purview of the FTC (Federal Trade Commission.) Therefore it may be for the government to help us with controlling some of these companies, which are taking advantage of men, many of whom are in dire straights because of Peyronie's disease and men who simply want to have a larger and longer penis. At this time I can see no reason to use any of these over the counter or internet-related products as we do not know what they contain and this may result in potential toxicity. Of note, for the older man with Peyronie's disease who is trying these agents, great care must be used in looking at all of the ingredients in these compounds as some of them contain androgens (DHEA, androstendione, testosterone) which may potentially result in more side effects than benefits for this age group. In addition, they have not been shown to have any reliable benefit. The bottom line here is save your money.close

Dr. Mulhall answers: Penile shortening and loss of stretch during erection are recognized as the biggest complaint of patients with Peyronie's disease. By the time that most men present to a doctor for Peyronie's disease they have generally noticed that their penis is shorter during erection and may even appear shorter in the flaccid (soft) state. The shortening is the result of the scar tissue. Scar tissue is non-expansile (non-stretchy) and indeed contracts during its development. Theoretically, if there was a treatment that reliably and consistently softened scar tissue, its use might translate into some length gain. However, there are no medical treatments identified which routinely result in regain of penile length. Some authorities believe that the earlier a patient arrives for treatment the better the outcome. Indeed, if treatment is started early it may prevent progression of the condition and may result in less length loss. At this time there is no medical evidence to prove that this approach will result in such an outcome.close

Dr. Levine answers: There is no best treatment for Peyronie's. Much of the treatments are based upon the degree and duration of the deformity, the presence of pain or calcification and one's own erectile function. Unfortunately, there is no evidence of any truly effective oral therapy for Peyronie's disease and topical treatments have also not been shown to be beneficial. Various types of topical energy delivery systems including iontophoresis have been used with reports of mild benefit. Injection therapy with verapamil or Interferon has been reported to be beneficial as well. None of these therapies have been shown to be a cure, but may result in some improvement of deformity in 40-60% of men. Shock wave therapy has been used in several countries, but the emerging evidence is not very supportive of benefit. Lastly, surgery at this time remains the gold standard therapy for Peyronie's disease for severe deformity, which interferes with sexual intercourse. By the end of this year, there will be a new textbook directed to physicians around the world to educate them on Peyronie's disease. This book will be published by the Humana Press and is scheduled to be released in September 2006. My advice to you at this time would be to seek consultation with a urologist at a university medical center and to continue to follow this website as many of the noted experts in the world on Peyronie's disease do contribute to it. In addition, this website will likely be the place to find the most reliable updates on new treatments for Peyronie's disease.close

To my knowledge, there is no contraindication to the use of Adderall with PD, but the drug to drug interaction with Trental, L-arginine and Cialis is something you should discuss with your pharmacist.close

Pentoxifylline is an old oral prescription drug which is indicated to improve blood flow in the lower extremities of people with vascular disease. It has been found to have a non-specific phosphodiesterase-type inhibitor effect. This makes it somewhat like a non-specific form of Viagra. The critical part is that by its effect on increasing the amount of available nitric oxide, that this can have anti-fibrotic (anti-scarring) effects. Therefore, agents such as pentoxifylline, L-arginine and the type 5-specific phosphodiesterase inhibitors (Viagra, Cialis, Levitra) all have been shown in experimental models to reduce the production of scar in an animal model of Peyronie's disease. L-arginine in particular is the precursor to nitric oxide and therefore, is felt to potentially increase the amount of available nitric oxide. L-arginine is an over-the-counter, relatively inexpensive amino acid. Collagenase is an enzyme which breaks down collagen. There are many different types of collagenases, but only a few works in mammalian systems to breakdown the type of collagen we find in human scar. At this time, there is research ongoing to study the use of collagenase made by a bacterium known as Clostridium. This is a non-specific collagenase which will break down all types of collagen and is very toxic when not used properly. Therefore, the clinical trials will be very carefully monitored by the FDA. There have been delays in the development of the trials by the sponsoring company, but it is hoped that by the end of 2007 that phase II trials will begin. Collagenase was first reported as a possible treatment for Peyronie's disease as an intralesional injection in the 1980s. Unfortunately, the studies done over the past 20 years have been weak and have not been readily accepted by the FDA.close

Pentoxifylline has been shown in animal studies to potentially reduce the development of the Peyronie's scar when the animals consumed the Pentox in their drinking water from the time that the Peyronie's process is triggered. Pentoxifylline is indicated to enhance blood flow to the lower extremities in patients with peripheral vascular disease likely because it has a mild non-specific vasodilating effect. Therefore, it is possible that it can increase blood flow in the man with PD. As to whether this will improve erections or has anything to do with preventing progression of already established PD is unknown. Niacin, to my knowledge, has not been studied as a treatment for Peyronie's disease.close

You are clearly doing your homework investigating the research on Potaba which was a very well conducted placebo-controlled trial. This study did show stabilization of the disease and some reduction in plaque size in those patients who received Potaba, but there was no evidence of improvement of deformity. In my opinion, if this drug were inexpensive, caused no side effects, and did not require ingesting 24 tablets a day, it may be worth considering. But given that there is no improvement in deformity, in my opinion there is little evidence of benefit with this agent, and the cost, side effects, and large number of tablets make the consumption of the drug inconvenient. I am therefore not a fan of using Potaba at all. There is certainly no contraindication to using this combination with verapamil or interferon injections, but I think other oral agents may make more sense such as pentoxifylline and L-arginine.close

The use of iontophoresis for Peyronie's disease has primarily focused on the Physion device from Italy. This is a device which delivers the positively charged energy via a reservoir which is filled with the verapamil with or without the decadron solution. My experience with this device is that 50-60% of treated men have mild improvement of their erect deformity ranging from 5-30 degrees but on average being around 10 degrees. Therefore I typically do not use this approach in men who have more advanced curvature, unless they are also experiencing a good deal of pain. This treatment modality has been shown to accelerate resolution of pain. The experts in the use of iontophoresis have informed me that the penetration of verapamil into the underlying plaque can be enhanced with decadron. Therefore since it appears that one drug does help the other it is best to give them together. Given that you have lost a lot of size and still appear to have significant Peyronie's disease, the non-surgical treatment options would include intralesional injection therapy with verapamil or interferon. This may be utilized with vacuum therapy in effort to stretch the scar tissue as well. For men who have strong erections but severe deformity and are not responding to medical treatment surgery is the next option with either a plication or a grafting procedure depending on the severity of the curve. For those men who have a combination of erectile dysfunction and deformity this situation is best treated with placement of an inflatable penile prosthesis where manual modeling is used to straighten the penis.close

Dr. Levine answers: There is no evidence that any specific medication will activate or cause Peyronie's disease. It is likely that the erections may have been somewhat diminished as a result of your high blood pressure, and made you more subject to activation of the Peyronie's disease during intercourse. Most men do not recall any specific injury that may occur during sex, but it does appear that the most common trigger to activate this process in the susceptible man is mild trauma during penetrative sex or vigorous masturbation. Given that there is no evidence that any medications cause Peyronie's disease, getting off your high blood pressure medication will not likely help, and may make it more difficult to control your high blood pressure. Therefore, please see your physician about proper blood pressure control, and your urologist with regard to the Peyronie's disease.close

Dr. Levine answers: Fexofenadine, also known as Allegra, is an antihistamine. At this point, I am unaware of any formal studies done to examine the use of this agent for the treatment of Peyronie's disease for any symptom whatsoever. Again it is possible that anecdotal reports are circulating by either physicians or individuals who are trying these products randomly, but again there is no known rationale as to why these agents would work, and no studies to support their use.close

Dr. Levine answers: It does appear that you have developed erectile dysfunction. It would be my advise that you seek evaluation by an erectile dysfunction/Peyronie's disease expert who could perform the proper studies to see if you may be a candidate for the following medical treatment such as vacuum therapy, intracorporeal injection therapy, intraurethral therapy or, of course surgical correction with and without the above noted therapies or most likely with a penile prosthesis to provide straightening and rigidity when you want it. If you are having problems with maintaining an erection even with a constriction band, it does suggest that you are having more advanced venous leakage, and therefore it is likely you will need placement of a prosthesis as noted above.close

Dr. Levine answers: Virtually all of the current modalities for treatment of Peyronie's disease can be offered to patients who are on anticoagulant therapy including Coumadin. The primary precaution to using a type of invasive therapy such as intralesional injections is bruising. To reduce bruising, compression of the injection site should be maintained for at least 10 minutes. In addition for patients who are considering the use of vacuum therapy, either alone or in concert with intralesional injection, then one must be very careful to not initiate vacuum therapy for at least 48 hours after an injection and to limit the pressure so that they do not develop any significant subcutaneous bleeding. Should bruising occur, manual pressure can be applied directly over the area of black and blue and then with subsequent use of the vacuum device, a lower vacuum pressure should be used.close

Dr. Mulhall answers: We know that TV is absorbed into the circulation as it appears in the urine of men who use so it is likely that all of the TV is removed from the skin by absorption into the circulation within hours. Therefore, a longer duration of application is unlikely to result in better tunical penetration. The use of iontophoresis can drive verapamil into the tunica however studies to prove that this results in deformity changes have not yet been conclusive.close

Dr. Mulhall answers: Pentoxyffline is a medication that has been used for decades for men with lower limb vascular problems and in in vitro fertilization (IVF) laboratories for the activation of sperm. Recently, Dr. Tom Lue at UCSF has suggested that using pentoxyffline (also known as Trental and called 'pentox' on the street) may result in some benefit to the Peyronie's disease patient. However, there has been no formal analysis of the effectiveness of this strategy (I refer to the section on this website on 'interpreting the medical literature'). Thus, in my opinion, it currently ranks up there with vitamin E as a treatment. Future study may prove it of benefit but at this time it should be considered empirical and investigation.close

Dr Mulhall answers: While some medications (such as beta-blockers for high blood pressure) have been linked to the development of Peyronie's disease there is really no good medical evidence to prove that this is the case. Indeed, there is some data that suggests that medical conditions such as high blood pressure, diabetes and cigarette smoking may be risk factors for Peyronie's disease and therefore medications used in these conditions might be used more commonly in Peyronie's disease patients. Doctors talk about association rather than causation and it is likely that this is the case for the link between medications and Peyronie's disease. With regard to the link between procedures such as cystoscopy (the placement of a telescope into the bladder though the urethra), there is a tiny amount of evidence that that this might be related in rare cases. However, causation is difficult to confirm for 3 reasons (i) there are thousands of cystoscopies that are performed annually and yet Peyronie's disease is relatively uncommon (ii) most Peyronie's disease plaques occur on the dorsum of the penis and any link between cytoscopy and Peyronie's disease would result only in a ventral plaque and the latter accounts for less than 10% of all Peyronie's disease plaques and (iii) only a tiny percentage of men who have ventral plaques have ever been exposed to a cystoscopy or any form of urethral manipulation (such as a urethral catheter placement). Thus, it is possible that such procedures may be associated with Peyronie's disease but at this time there is little good evidence that cystoscopy or other such procedures or manipulations cause Peyronie's disease.close

Dr. Levine answers: I am delighted that some of the APDA website subscribing patients are experiencing benefits from topical verapamil however, based upon the many men I have seen who have tried topical verapamil none have noted any significant benefit what so ever. There is, of course, a population of men who may have spontaneous resolution of their deformity. In the modern literature it has been reported as being less than 13% of men experience resolution of their penile deformity. In addition, there is a population of men who injure their penis, develop a normal scar, which over the course of time heals spontaneously following the normal healing process. This is not Peyronie's disease. Although some pharmacists claim that the drug takes only five minutes to "soak in," so far the research which has been done on one brand of topical verapamil, has not demonstrated that any drug truly gets to the target tissue (i.e. the tunica albuginea), which is where the Peyronie's plaque develops. Therefore, a 10-minute application may be just as good as a 2 minute or 2 hour application. The irritation that you experience may be due to topical vaso-dilation (blood vessel engorgement) caused by verapamil, or it may be due to the various emollients and enhancers that are in the gel/cream. If you want to continue with this therapy, one option would be to consider application of a 1% topical steroid cream, which can be purchased over the counter and applied after you wash off the drug. In terms of continuing with treatment, another option would be to step up the therapy to either an iontophoresis program, which has been demonstrated experimentally, in one study, to reach the target tissue in 70% of patients, and can be done at home. The Physion Company of Italy now has FDA approval in the U.S.A. for their iontophoresis (EWDA) delivery system for verapamil. About 50% of my patients have demonstrated improvement when using verapamil solution or even saline alone. Prior research has suggested that electric current may in fact activate the healing process, which may explain why some men with saline respond to this treatment. Further research is ongoing regarding this phenomenon. Another approach where you could continue verapamil would be to find a Urologist in your neighborhood who might be interested in injecting verapamil directly into the plaque, which is performed every two weeks for 6-12 injection treatment sessions.close

Dr. Levine answers: Collagenase injections are not yet available for clinical use nor have the clinical trials begun. Auxilium, the pharmaceutical company who is investigating collagenase is developing a placebo-controlled trial that must go through FDA approval before initiation. These negotiations as well as finalizing the manufacturing process for the collagenase must be completed before initiation of the trial which we hope will begin sometime in 2007.close

It is my opinion that the injection therapy used for the treatment of ED does not cause Peyronie's disease. What the injection therapy does do is cause a stronger erection which may be more apt to get injured during sexual intercourse. In the susceptible individual this could activate the abnormal scarring process resulting in the Peyronie's deformity. This assumes that the injection therapy is being done properly, where it is injected into the side of the shaft of the penis. Following injection the site is compressed for 3 to 5 minutes to prevent internal bleeding. Most commonly the scarring which occurs after penile injection therapy for ED is within the vascular erectile tissue and not in the tunic of the penis where Peyronie's develops. In spite of the above I am concerned about using injection therapy in men with existing Peyronie's disease. Many men with Peyronie's disease also have erectile dysfunction which may not respond to oral medications such as Viagra, Levitra, or Cialis. In that case intra-urethral therapy with MUSE is recommended as this treatment is less likely to activate PD. Penile injections can also be used if the other treatments fail. Ultimately for the man that has advanced erectile dysfunction and Peyronie's disease placement of a penile prosthesis may be the best option to provide straightness and rigidity.close

Dr. Levine answers: In my opinion, the use of steroid injection is contraindicated as it can cause tissue atrophy, disruption of the normal tissue planes between the plaque and the overlying nerves and blood vessels that supply the penis, and lastly the historic papers on this therapy have not demonstrated any significant benefit. Therefore, I would strongly suggest not using any form of injectable steroid.close

Dr. Levine answers: Collagenase is an enzyme which breaks down collagen which is the primary component of the Peyronie's plaque. Studies using collagenase began in the 1980s. These showed some benefit but not necessarily dramatic benefit in the early studies that were done at that time. Unfortunately because of lack of funding, the company who owned the drug was unable to complete the necessary trials to demonstrate true clinical benefit. More recently, a company has purchased the rights to that drug and is planning to pursue FDA approval for the use of collagenase for Peyronie's disease. The protocol is currently in development and to my knowledge, no collagenase injections are being given anywhere. I am sure that once the studies begin there will be notification on this website so that interested parties may determine whether they are candidates for the clinical trials. The overall concept is to use the collagenase much like a "chemical knife" to literally dissolve the scar tissue and hope that the tissue will remodel in such a fashion to reduce the deformity caused by the scar. We will need to wait and see on the outcomes from the trials before making further conclusions. Verapamil still appears to be the most sensible injection therapy for PD.close

Dr. Levine answers: There is no evidence that Botox has a beneficial effect for Peyronie's disease. There have been multiple reports on the use of Botox for a variety of problems, but this is a chemical which acts as neuromuscular paralyzing agent, and at this point there does not appear to be any evidence that it has any beneficial effect upon fibrotic tissue or scar.close

Dr. Levine answers: In my opinion when a man goes through an injection therapy with verapamil or Intron A, and there is no visible benefit of the erect deformity of the penis following a course of 6 injections, then further injection is unlikely to result in any substantial benefit. Recently it has been reported that increasing the dose of verapamil from 10-20 mg may further enhance the results and in my experience, patients who are inclined to continue on injection therapy in lieu of undergoing surgery are offer a higher dose of verapamil. I am not sure whether the experts using interferon are pushing the dose beyond 5 million units at each injection. Alternatives to stopping injection ultimately are surgical or no treatment.close

Dr. Mulhall answers: There has been no study of human growth hormone (hGH) in Peyronie's disease. I am unaware of the ability of hGH to dissolve collagen or scar. In all of the medical conferences that I have attended in the past decade that have included Peyronie's disease research presentations, I have never seen any paper presented on this agent. If you are aware of any centers involved in such research please alert us.close

Dr. Mulhall answers: The evidence supporting the use of oral colchicine is weak although Peyronie's disease cells react favorable to colchicines in a test tube. The main requirement for the use of any medication as an intralesional agent is that it is safe when given intravenously (as some of the drug will be absorbed from the veins above and below the plaque). Colchicine has never been explored as an intravenous agent and therefore cannot be used intralesionally.close

Dr. Levine answers: The current recommended regimen for verapamil injections is an injection of 10 mg of verapamil diluted in 10 mL of fluid. This is administered with a standard syringe with a 5/8 inch 25-gauge needle. I have found that using a smaller gauge needle may not allow adequate distribution of the drug into the plaque and a smaller needle is at higher risk for breaking. Using a 25-gauge needle, in more than 10,000 injections, I have never had a needle fracture. These injections are done no more frequently than every 2 weeks, but can be done every 2-6 weeks depending upon the patient's and physician's schedule. The goal is to perform a total of six treatments, and then determine whether the patient notes some improvement of his penile deformity including diminished curvature, enhanced girth, softening of the plaque and better erectile function. If there is evidence of improvement following six injection treatments, then I recommend continuing for another 6 treatments for a total of 12 visits. It is worth noting that not all experts agree with this latter plan. Recently, researchers in Texas have suggested increasing the dose to 20 mg of verapamil in 10 cc's of solution if there is no improvement after six injections. I have initiated this with great caution as a higher dose of verapamil could possibly have some cardiovascular side effects (i.e. lower blood pressure). None have been reported with the 10 mg dose in my experience or the 20 mg dose from the Texas group. The concern that direct needle trauma could result in worsening of the plaque is a real one; as it is assumed that Peyronie's disease is triggered by trauma to the penis. Yet, I have only seen 6-8% of patients with a measured worsening of curvature following verapamil injection. I believe this is a result of the anti-fibrotic mechanism of the verapamil therapy. I am unaware of any studies which have looked at dry needling (where the plaque is simply needled, but no drug is injected) to know whether just needling the plaque itself would cause worsening of scar or potentially improvement of curvature. It should be recognized that during the injection process, the plaque itself may become larger with a change in shape. My experience has shown that over time, once the treatment has been completed, the plaque will tend to reduce in size and in some men the plaque becomes virtually nonpalpable. This may take one or more years to occur.close

Dr. Levine answers: The use of the cortisone, or any form of steroid injections for Peyronie's disease, was most commonly used in the 1960s through the early 1980s. Theoretically steroids will reduce scar formation by inhibiting fibroblasts from making the primary components of scar, that being collagen. Unfortunately, all steroids can result in tissue atrophy, with weakening of the tissues, and do appear to result in a destruction of the planes between the bundle of nerves and blood vessels which lie over the Peyronie's plaque. As a result, should the steroid injection therapy fail, which it does regularly, this may make surgery more complicated and comprise neurovascular function of the penis. The primary concern with steroid injection, as with many of the treatments for Peyronie's disease, is that virtually all of the studies in the past where not controlled with a placebo arm, they were performed with a limited number of patients whose improvement was only reported subjectively without any measurements documenting reduction of deformity. Although there are physicians around the world who may still be using steroid injection, it is my opinion that this should not be used as there are better and safer alternatives such as, verapamil and interferon, which are currently available.close

Dr. Levine answers: To my knowledge, there is no evidence that taking calcium, as a supplement would encourage calcification of a Peyronie's plaque. This calcification of plaque is likely a genetically governed process, which is unlikely altered by taking extra calcium or no calcium at all.close

Dr. Levine answers: It may be that you have an early form of Peyronie's disease, which is either spontaneously recovering which occurs in less than 10% of cases, or may be responding to the oral and topical medicines that you are using. Unfortunately, there is very little evidence that vitamin E works at all and should be used at 400 units daily to avoid the reported vascular complications. Topical hydrocortisone is likely to have no benefit, and I do not recommend using it at all.close

Dr. Levine answers: Vitamin E may be used on a daily basis, but not more than 400 mg. Again there is no evidence that vitamin E truly benefits Peyronie's disease, but it may have some potential benefits as an antioxidant and to prevent prostate disease, in particular prostate cancer.close

Dr. Levine Answers: This is a good question, as collagenase is an enzyme which breaks down collagen which is the primary component of a Peyronie's plaque. Collagenase has been studied since the early 1980s. Recently there has been increased interest in the use of collagenase as a treatment for Peyronie's disease as an injectable agent into the scar. The company that did the original studies has given rights to investigate this product further to another company who is in the midst of developing a protocol. No studies have been conducted to our knowledge, but will certainly be subject of reports when they become available. Collagenase is not available at this time in any part of the world, and likely will be studied first in the United States.close

Dr. Levine answers: No. There is no evidence that topical verapamil has any proven benefit. The only study, which has been done by a group independent from the manufacturer, demonstrated no evidence of penetration of the topical verapamil gel into the underlying plaque tissue. Therefore, until properly performed and validated placebo controlled trials of topical verapamil are done which demonstrate a true benefit with regard to deformity of the penis, the Medical Advisory Board of this website cannot support the use of topical verapamil. Personally, we suggest that you save your money and considering seeing an expert in the field first.close

Dr. Mulhall answers: There is no long-term data on ultrasound therapy and no study done in a randomized, controlled fashion.close

Dr. Mulhall answers: There are no known over-the-counter products of benefit in Peyronie's disease. Most urologists know little about this condition and are generally not completely up-to-date on treatments and we suggest that you seek out a Peyronie's disease expert for evaluation and a discussion of treatments.close

Dr. Mulhall answers: Dr. Larry Levine from Chicago has shown very elegantly that the use of iontophoresis allows verapamil applied to the skin to be absorbed into the tunica albuginea. This is in direct contrast to the use of transdermal verapamil without iontophoresis, as it has been clearly shown that in this case no verapamil gets absorbed into the tunica albuginea and so most experts believe that regular transdermal verapamil has no chance of working. There is a small amount of evidence that iontophoretic delivery of verapamil may be of some benefit, however, the structure of the studies to date preclude any definitive answer to the question. There is some debate among experts as to what the purpose of medical (nonsurgical) therapy is: is it to correct the deformity or is it to prevent it worsening? I would contend that the latter is more achievable that the former but there are some men who obtain an improvement in curvature with medical treatment. The bottom line is that the final answer is not known yet. Most importantly, transdermal verapamil is not dangerous. Verapamil is used primarily as a blood pressure agent so the rare man may have a slight drop in blood pressure but it is generally accepted to be a very safe agent. The only concern would be that if it is shown that it is not effective that men may have been wasting time in ignoring other treatments.close

Dr. Levine answers: I have no experience with the use of DMSO, alone or in combination, as a form of therapy for Peyronie's disease. I am also not familiar with any medical studies demonstrating any benefit from using DMSO, apple cider vinegar and/or castor oil for Peyronie's disease. All of these may have some reported benefits with regards to treatment of scarring. But this type of therapy truly falls within the realm of complimentary alternative medicine with no evidence based medicine report to support their use. Therefore should anyone elect to use these types of alternative therapies, it is at their own risk, and likely with little benefit.close

Dr. Mulhall answers: I am not familiar with the specific product you mention, however, here is what we know about transdermal therapy. There is not a single medical paper in the literature on the effectiveness of transdermal verapamil (go to PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) to search for papers on Peyronie's disease) without the use of iontophoresis. We have demonstrated that applying verapamil gel to the skin fails to penetrate the tunica albuginea (Martin DJ, Badwan K, Parker M, Mulhall JP. Transdermal application of Verapamil gel to the penile shaft fails to infiltrate the tunica albuginea. J Urol. 2002 Dec;168(6):2483-5). The use of iontophoresis (a low-grade electrical current, which drives the medicine across the skin) has been shown to allow penetration of the drug into the tunica (Levine LA, Estrada CR, Shou W, Cole A. Tunica albuginea tissue analysis after electromotive drug administration. J Urol. 2003 May;169(5):1775-8). There are 3 papers in the literature that have assessed iontophoresis with various medications and have demonstrated modest curvature improvement. The bottom line here is that much of the hype appears to be driven by considerations other than effectiveness without any supporting evidence that this treatment really works. I do not use this in my practice and have not seen a single patient who has used it who has experienced any benefit. However, it is possible in the future that Verapamil (or other drugs) may be used with iontophoresis in this condition. Of note, Dr. Larry Levine at Rush-Presbyterian Medical Center in Chicago is currently conducting a study assessing iontophoretic delivery of verapamil.close

Dr. Levine answers: Vitamin E is probably the oldest oral therapy used in the modern era for Peyronie's disease. Unfortunately there are no well done controlled trials demonstrating any benefit, and in a small controlled trial performed in England, no benefit was noted with the use of vitamin E for Peyronie's disease. The proposed mechanism of action for vitamin E is as an agent which may act by soaking up scar-inducing chemicals (free radicals) that are released in traumatized, inflamed and healing tissue. Therefore, if vitamin E could possibly get into the tunica albuginea of the penis and lower the free radicals then vitamin E would be beneficial. Unfortunately, there is no evidence to show that vitamin E does reach the target tissue, and it is unknown what dose would be necessary to result in such a benefit. In my opinion, vitamin E remains relatively inexpensive and non-toxic treatment when used at less than 1000 units per day and may have some benefit and does little harm. Although there may be different types of vitamin E, to my knowledge, there has been no evidence of an increased benefit with one brand or type over another with respect to Peyronie's disease, and therefore your questions regarding hi-gamma vitamin E must go unanswered. There is increased concern about using high doses of vitamin E in patients who may be at increased risk for congestive heart failure. Therefore, in the man who may have a compromised heart, the use of daily vitamin E, at any dose, has raised concern and probably should be avoided until more conclusive information is available. One final comment is that vitamin E is now under study in the US in a large government sponsored trial examining the potential benefits of 400 mg/IU vitamin E daily. These men will be followed over a 7-12 year period to see if such chronic use would reduce the risk of prostate cancer as compared to no vitamin E versus the combination of vitamin E plus selenium 200 mcg daily. In the recent past small, short-term trials of vitamin E and Selenium have suggested a reduced risk of not only prostate, but also colon and lung cancer. The government sponsored study, known as the SELECT Trial is attempting to answer this question.close

Dr. Mulhall answers: These agents are called nutriceuticals, that is, compounds purported to be drug like but "all natural". These compounds are not under FDA control and therefore any claims can be made without substantiation. The nutriceutical subcommittee of the Sexual Medicine Society Of North America (www.smsna.org) recently declared that there was no nutriceutical that was any better than placebo in the management of ED. While no formal analysis of Peyronie's disease products has been conducted it is likely that the conclusions will be identical. I would urge all readers to encourage the companies making these products to subject them to rigorous, placebo-controlled studies to answer the question are they worthwhile using.close

Dr. Levine answers: There are no formal studies which have been done on liquid or oral chelation products. Although patients have suggested that there has been some improvement or reduction of calcification of plaque as a result of using chelation agents, this is totally unproven, and frankly not likely the case. There would be no reason whatsoever to use any chelation agent when the plaque is not calcified.close

I have not seen any beneficial effects of iontophoresis with verapamil and/or dexamethasone in improving plaque calcification in my experience or in the published. Therefore, in my patients who present with substantial plaque calcification iontophoresis is not recommended and in fact, there is no known non-surgical treatment for extensive plaque calcification. Typically surgery is indicated if the deformity is compromising sexual activity. The group at UCSF has suggested that the use of oral Pentoxifylline over time may change the amount of calcification within the plaque, but this has yet to be confirmed in published studies.close

Electromotive drug administration (EMDA) has been reported to have benefit when used for Peyronie's disease in several publications. It appears that the best combination of drugs as reported by DiStasi is when verapamil (10 mg) and dexamethasone (4 mg) are used 3-4 times per week for at least 3 months. A control group study reported by Greenfield and Levine examined EMDA with verapamil alone versus saline alone. Both groups showed benefit with no statistically significant difference in improvement between the two groups. Overall, the improvement was fairly modest at around 10-11 degrees on average for both groups. This is in comparison to DiStasi's report where 43% had at least 20 degrees of measured curvature improvement. As to why the saline only control group had measured improvement, it has been suggested that the electrical energy itself may have beneficial effects with respect to encouraging wound healing. Electrical current has been used in a variety of dermatologic disorders and has been known to result in accelerated wound healing. The primary benefits of EMDA are that it can be done at home, it is not painful or invasive, and it appears to have a very low rate of adverse side effects. However, it is costly and in my opinion, is best used in patients with mild to moderate degrees of deformity and/or in patients with pain, as pain resolution seems to be accelerated with EMDA.close

Dr. Levine answers: Various forms of external energy have been used to treat PD in non-randomized trials including topical ultrasound and lasers. The mechanism is unknown, but it has been suggested that ultrasound and laser treatment may enhance tissue healing. I am not familiar with any studies which have demonstrated any benefit with ultrasound or laser and therefore, cannot speak to the specific modality or energy level that should be used for ultrasound treatment of Peyronie's disease. One treatment that has gained some attention in Europe and recently in the U.S. is iontophoresis or electromotive drug administration (EMDA). This treatment provides electric current to drive drugs through the skin into the underlying scar tissue. Studies have shown that EMDA can indeed drive verapamil into the plaque tissue and therefore may make some sense. More recent studies have suggested that the combination of verapamil and dexamethasone may provide the best outcomes with regard to improvement of deformity and rapid reduction of pain. But, the overall reduction of curvature tends to be small, in the 10-30 degree range. In my opinion, iontophoresis would be useful in the patients with mild to moderate curvature only or those who also have significant pain, as the EMDA treatment does seem to result in rapid resolution of the pain.close

Dr. Levine answers: I recommend that you examine the topic section within this website on the use of shockwaves, and previous answers to questions on this subject. Basically at this point there is no evidence that the use of shockwaves for Peyronie's disease is an effective therapy. Several patients have noted improvement, whether this occurs as a result of contralateral scarring that falsely straightens the penis or whether there truly are beneficial effects have not been proven, but in the studies which have been done, very little benefit has been reported in the medical literature.close

Dr. Mulhall answers: Whenever a test has been ordered the physician (and the patient) should ask themselves how the results of the test will alter the plan of treatment. If the answer is "not much" then the test is probably not indicated. Over history, numerous imaging studies have been employed including x-rays, ultrasound and MRI. X-rays have been used to assess for calcification. Calcification usually indicates the presence of late stage disease. The x-ray can show calcium deposits. However, calcification is often not complete, that is that it is in one part of the plaque and not throughout the entire scar. Furthermore, the most significant calcification can be diagnosed by an experienced urologist by plain palpation (feeling the plaque). When MRI became readily available there was great interest in using it in the imaging of men with Peyronie's disease. There is no doubt that it gives beautiful pictures however, it is rare that such pictures will change how the physician plans to proceed. Ultrasound of the penis can be used to examine the scar, its size and calcification, but can also be used to evaluate penile blood flow before surgical reconstruction. Some authorities are interested in plaque volume, however others (including myself) are less interested in this and more interested in functional factors such as degree of curvature and ability to have sex. However, I would agree that all men undergoing penile reconstruction surgery for Peyronie's disease should have an assessment of their penile blood flow beforehand as this may impact upon the choice of the procedure for the individual patient. The bottom line is that except for the preoperative patient, imaging is not absolutely necessary although individual physicians may perform such imaging in their practices.close

Dr. Mulhall answers: Extracorporeal shock wave therapy (ESWT) is a therapy where shock waves are aimed at tissue or structures to disrupt them. It has been used in many conditions although it has been used most frequently for the fragmentation of stones inside the body, such as gallstones and kidney stones. For these conditions it has proven to be an excellent treatment and represents the primary treatment of small stones in the kidney. Based on the application of this therapy in orthopedic medicine for a variety of conditions some researchers in Europe applied ESWT to Peyronie's disease. The concept is intriguing as we as of yet do not have an excellent medical therapy for reversal of penile deformity in Peyronie's disease. The concept is that the shock waves when applied to the scar (plaque) can disrupt it, perhaps resulting in an improvement in penile deformity. It remains unclear exactly what the mechanism is by which ESWT correct penile curvature. As of February 2004 there are 17 papers in the literature discussing the use of ESWT in Peyronie's disease. Unfortunately, there is no consensus among any of the centers that are using this technique as to what the correct machine to be used is (there are many different kinds of machines used for shock wave therapy), how many shocks should be applied to the penis and at what energy, and finally how many sessions should be used. The studies exemplify many of the inadequacies of the clinical Peyronie's disease literature in general, specifically the absence of a control group (there should be a group of men who received "fake" ESWT to ensure that the treatment is actually resulting in correction and that it is not just the natural history of the condition), small numbers and inadequate follow-up. Finally, there is not a single study that has shown that ESWT applied to the penis is safe. Theoretically, shockwaves should be damaging to erectile tissue causing scarring from the trauma that shock waves cause. Scarring in erection tissue could have a significant negative effect on erectile function perhaps leading to erectile dysfunction (softening of erections). The best conducted studies have shown a 21-64% incidence of penile deformity correction, although most of these studies have less than 30 patients studied, have no control group and have less than 12 months follow-up on the patients. While it is likely the reason that ESWT has not received widespread acceptance by urologists in the USA is the lack of insurance reimbursement, the safety concern is the main reason that the experts have not yet commenced large-scale ESWT programs for Peyronie's disease. At this time, most authorities are encouraging patients to be cautious. If you are considering this option speak to an expert before you do so.close

The 3-cylinder (SOMA) vacuum device has been recommended as a non-surgical treatment for Peyronie's disease. My personal approach has been to start with the largest cylinder so as to accommodate the curvature when it first presents. As the curvature and deformity responds to the pressures created by the vacuum tube, one should progressively go to the middle and then the smallest of the caliber cylinders. I typically recommend that this progression occur after at least one month of use of each cylinder, which should be applied for 20-30 minutes at least once, but possibly better 2-3 times per day. There is no need to apply the constriction band. I recommend that the pressure be maintained throughout the 20-30 minute treatment period rather than using a repetitive inflate/deflate process. It seems to me the effects of traction are best transmitted with prolonged application rather than with intermittent application. So far there are no published reports showing benefit with traction therapy, but hopefully a formal trial will be conducted in the near future which will provide better insight as to whether vacuum therapy really works to correct PD deformity.close

Dr. Levine answers: The vacuum therapy has been suggested for several years to be a potential treatment for Peyronie's disease to stretch the scar tissue and thereby result in straightening. Unfortunately, there are only anecdotal, unpublished reports on this approach. Currently there is a study in Chicago comparing the results of verapamil alone to verapamil plus vacuum therapy, using the three piece vacuum system. The results of this study are not yet available, but in my opinion, it does seem to make sense to combine medical therapy with the hope that the drug may affect fibroblast behavior, which is responsible for the scarring, as well as applying mechanical forces to stretch the tissue and to encourage further remodeling and straightening of the penis. The key is that the device needs to be applied daily for no longer than 30 minutes per treatment, but these treatments can be done 2-3 times per day if the time is available to do so. So far there have been very few reports in the medical literature that a vacuum device would cause Peyronie's disease, but again it is unlikely that the device so much causes it as it does result in an erection which can then be injured activating Peyronie's disease in the susceptible individual. Currently I am using combination therapy of verapamil injection with external vacuum therapy using the three cylinder VED device.close

Dr. Levine answers: The use of a penile extender or stretching device appears to have a similar goal to that of a vacuum device. That is, to try to apply stretching forces to the penis to encourage remodeling of the scar tissue. It seems intuitive to me that if one could get straightening of teeth by applying chronic forces with braces, we might get this same type of benefit from applying prolonged stretching forces to the curved penis. The problem is how much force can be applied, how to apply it, and how to apply it without causing injury. A study of one of the penile extender devices is beginning in Chicago currently to examine the effects of stretching therapy alone on penile deformities associated with Peyronie's disease. This is a 6-month study and therefore when the data becomes available it will certainly be posted on this website, likely by mid-2007. In the mean time, I would only recommend the use of an external penile stretching device when prescribed by a qualified physician after a full consultation and examination.close

Dr. Levine answers: The Physion device is unique in that it provides a reservoir, which is attached and sited directly over the Peyronie's plaque. This is why it is not a particularly good device or approach for patients with downward or ventral curvature as it is difficult to get exposure to the underlying plaque through the urethra. On the other hand, the other iontophoresis devices which are on the market, use a pad which is saturated with the chemical. As of this time, there are no studies which have been done on patients with Peyronie's Disease that demonstrate that these other devices do result in actual transfer of the drug into the underlying plaque. One study did show that with the Physion device that 71% of patients had measurable levels of Verapamil within their plaque when this procedure was performed prior to a surgical incision of plaque. Therefore at this time it does not appear that all iontophoresis devices are the same until further studies are performed.close

Dr. Levine answers: Vacuum appliances have been reported to have some potential benefit in men who have established Peyronie's disease. All of these studies are anecdotal reports on a limited number of patients, with no objective measures of improvement and no placebo control. It is my opinion that a vacuum device used properly may be able to apply mechanical forces to the penis to stretch the scar and possibly result in some straightening. I have been using vacuum therapy in concert with intralesional injection of verapamil over the last year. My current protocol is to use the vacuum starting at 5 minutes and building up to 30 minutes, once to twice per day. On the day of and the day after an intralesional injection, no vacuum is used so as to reduce the likelihood of bruising. The principle of vacuum therapy is to apply mechanical forces to the scar tissue on a prolonged basis much like applying braces to teeth which results in gradual straightening of the teeth due to remodeling of the bone around the teeth. It is possible that using other types of stretching tools such as the Fast Size or Andropenis device may provide the same type of mechanical stretching forces. To my knowledge, there is no study, which has looked at vacuum or stretching devices as a treatment for Peyronie's disease. I am aware of two protocols in development looking at vacuum therapy and the external stretching device used with or without intralesional verapamil injections to study the benefits of one treatment alone versus the two combined. It is my opinion that the combination of mechanical forces will enhance the potential beneficial chemical effects of the injected medication. This is only theoretical and I will make further recommendations based upon the results of these trials, which hopefully will begin sometime in 2006. It is important for people who are interested in using vacuum devices before these studies are done, that they use the devices carefully with gradual increase in pressure and gradual increase in duration of the vacuum forces. These forces should be applied in a continuous, not in an "up and down" approach as has been suggested by one of the firms making the vacuum device. Therefore, as the individual becomes more comfortable with the vacuum application, they can maintain the vacuum device on the penis, without the constriction band, for as long as but not more than 30 minutes. Exceeding this time period may create vascular injury to the erectile tissue. The goal is also to not only have the vacuum stretch the tissue, but the resulting curvature of the penis will press up against the interior wall of the vacuum tube which may also place mechanical forces to stretch and hopefully straighten the scar tissue.close

Dr. Levine answers: Please see the answer to the question above specifically regarding the use of traction devices. They have been reported to be left on the penis for as long as 8-12 hours which may be appealing as there is a longer duration of stretching forces. The concern is as to whether this can possibly injure the penis. One must also be cautious about a compression injury to the underlying tissue caused by chronic pressure. Therefore, until proper studies are done, I would recommend great caution in using any type of long term stretching tool on the penis for fear of causing injury. The good news is that there is interest amongst investigators to evaluate the potential benefits and safety of stretching devices and vacuum devices.close

Dr. Hellstrom answers: Vacuum constriction devices or vacuum erection devices (VEDs) have been used for the treatment of erectile dysfunction for many years. The device produces an erection-like state by creating a vacuum around the penis, rapidly drawing blood into the corpora cavernosa. After adequate tumescence and rigidity are attained, a constriction band is placed at the base of the penis to restrict the venous outflow. The ring of the device may potentially traumatize the penile vasculature, septum and tunica albuginea. PD has been reported rarely after the use of VEDs. Without the constriction ring, VEDs in theory should not cause Peyronie's disease, although there are a small number of reports of Peyronie's disease occurring in men who have used vacuum devices. There are a number of studies that currently are looking at the use of daily VEDs for the treatment of PD. Recently, VEDs have become popular for rehabilitation of the penile tissue, particularly after penile surgeries and radical prostatectomy, although this is controversial and un proven to date.close

Dr. Levine answers: The use of vacuum therapy has been considered a treatment option for some years without documented evidence of benefits. Several unpublished reports from physicians and patients have suggested that they have seen improvements with chronic use of a vacuum device. The suggested mechanism is that stretching the penile tissue on a regular basis encourages the remodeling of the tunica albuginea and this straightens the penis. Years ago the Russians used the principle of stretching bones with a surgically placed device and that this in turn results in bone growth to lengthen shortened limbs. The problem is being able to provide prolonged pressure to the penis that such a change could occur. The recommended approach that I have used with patients (without any clear evidence of benefits as of yet) is to apply the vacuum once to twice per day in a progressive fashion until they could tolerate leaving the device in place for thirty minutes. Using a pulse of vacuum for short term (i.e. 5 minutes) may not be beneficial and may potentially cause injury. Leaving the device on for any longer than thirty minutes is dangerous as it can cause a low oxygen state, which may cause vascular and internal damage. Studies that I conducted in the past using a vacuum device revealed that the apparent straightening of the penis with the vacuum on is due to the expansion of tissues deep to the skin, but superficial to the tunica albuginea. As a result of having girth enhancement around the scar tissue within the tunica, a masking effect of the deformity occurs which results in what appears to be a more full and straight penis. My opinion is that this straightening is not real and yet a multi-centered study is being developed to test the benefits of chronic use of vacuum therapy to straighten the penis.close

Dr. Levine answers: Yes, vacuum therapy can cause damage, but this has been reported very infrequently in the literature. Used properly, the likelihood of further damage to the penis with Peyronie's disease is low.close

Dr. Levine answers: The use of a penile extender or stretching device appears to have a similar goal to that of a vacuum device. That is, to try to apply stretching forces to the penis to encourage remodeling of the scar tissue. It seems intuitive to me that if one could get straightening of teeth by applying chronic forces with braces, we might get this same type of benefit from applying prolonged stretching forces to the curved penis. The problem is how much force can be applied, how to apply it, and how to apply it without causing injury. A study of one of the penile extender devices is beginning in Chicago currently to examine the effects of stretching therapy alone on penile deformities associated with Peyronie's disease. This is a 6-month study and therefore when the data becomes available it will certainly be posted on this website, likely by mid-2007. In the mean time, I would only recommend the use of an external penile stretching device when prescribed by a qualified physician after a full consultation and examination.close

Dr. Levine answers: A clinical trial with a stretching device is beginning in Chicago. This study is just getting underway and there is no data to report. Theoretically, one can reason that applying chronic mechanical stretching forces on tissue can result in remodeling of that tissue. We know that if we apply braces to teeth that in time the teeth can be mobilized to straighten them, which means that in fact, bone and underlying tissue is remodeled. Therefore, the concept of wearing a stretching device on the penis for an extended period of time can theoretically result in the same process. This needs to be proven and there is only one report that I am aware of out of Spain that indicated some benefit, but the data is very difficult to interpret. I would certainly not recommend utilization of stretching devices at this time, without the supervision of a physician, until we have results to report from properly performed studies. With regard to the loss of length in the obese man, there is no doubt that the penis may appear to become shorter as a result of the penis being fixed to the pubic bone and the fatty tissues being mobile over the top of the penis. Therefore losing weight in the lower abdomen and pubic area can indeed result in a better presentation of the penis, particularly in the flaccid condition. So if you are 70 pounds overweight-start to lose it right now.close

If the man has unstable PD associated with pain when the penis is stretched, then traction is not advised until the pain resolves or is treated. But, if there is no pain and the man can tolerate the stretching, then I do recommend use of traction therapy regardless of the onset of the PD. Our results continue to be promising with the FastSize device.close

There are several other traction devices on the market including the Jeez device and the Andro-penis from Europe. These devices all appear similar and work on the same principle, but may have some minor structural differences. The recommended protocol for use of external traction is that the device should be applied on a daily basis for a minimum of two hours, but it does appear that using it for longer periods of time each day (up to 8 hours) will result in better results. This makes sense as the longer the traction is applied, the greater the likelihood that tissues in the penis will respond and adapt to the applied traction force. The goal here is not simply to stretch, but possibly to result in a change in tissue configuration and possibly tissue growth in a multi-dimensional fashion. This may be correction of curvature, length gain and even some girth enhancement. With regard to combination therapy, it would make sense that when one approaches Peyronie's disease in a nonsurgical fashion, using a variety of mechanisms to enhance tissue change would be better than using just a single approach. This is especially true since to date, there is no non-surgical therapy that has been found to be uniformly successful. Therefore, studies are ongoing which are examining the effect of oral therapy with L-arginine and pentoxifylline combined with intralesional verapamil injections and daily use of the traction device as compared to injections alone. Preliminary data from Dr. Levine's group suggests that there is a more robust and earlier response when combination therapy is used over injections alone. Time will tell as to whether this theory holds out.close

Dr. Levine answers: This question pertains to men with severe disease, that being greater than 60-70 degrees of curvature and/or with destabilizing indentation or hinge. To be a candidate for a grafting repair the man must have good quality erections preoperatively with or without PDE5 inhibitors, such as Viagra, Levitra, or Cialis. It is critical that the patient have good preoperative erections as the primary risk of this operation is post-operative erectile dysfunction which has been reported to occur following this operation in 5-50% of men. In those who have very good quality erections, the new ED rate is in the 5-10% range. The goal of all operations for Peyronie's disease is to straighten the penis and make it more sexually functional. Regaining lost length and girth is an added benefit, but can not be expected routinely. By and large the grafting operation will result in a gain of 1-3 cm in the area of maximum deformity. That is to say, if the curvature is upward with a 90-degree bend, by incising or partially excising the scar tissue the length of the top surface will increase allowing all dimensions of the penis to be equal, thus making it straight. As part of the grafting operation, areas of indentation may also be corrected with the partial plaque excision; the graft will then provide of a more normal caliber penis, thereby enhancing width in that area only. With regard to post-operative care, there is little evidence that the vacuum device will enhance length and girth post-operatively. On the other hand there is one abstract and increasing experience amongst experts in the field that when daily traction therapy is applied to the penis, that further loss of length can be prevented and possibly lost length before surgery can be regained. This is measured as 1-3 cm (1/2-1¼ inch) after surgery beginning two-three weeks post–operatively, when the wound is capable of taking some pressure. Traction must be applied on a daily basis for a minimum of two, but better with four to eight hours per day. The key to traction therapy is the daily use. In addition, those men who apply the device for a longer period of time each day do better than the men who apply it only two hours per day. The current traction devices are available for purchase online, and at this point although FDA approval is being sought, insurance companies are not covering the costs for this device.close

Plaque incision and grafting (PIG) is an excellent option for men with significant curvature (greater than 45 degrees), young age and normal erectile function. The success rate defined as having a straight erection after surgery is greater than 85%. However, it is associated with some side effects the most notable one being problems with erection. In our database those patients most likely to develop erectile dysfunction after PIG surgery are men over 55 years of age, men with pre-existing erection difficulties (even mild ED) and curvatures greater than 60 degrees. This is a complicated operation that should only be done by a surgeon with significant expertise ion the procedure.close

Dr. Mulhall answers: PD causes shortening and sometimes narrowing of the penis because of the scar contraction that is associated with PD. The placement of many of the inflatable implants results in widening of the girth but no increase in length. Patients in my practice with PD usually are implanted with the TITAN device from Coloplast, which is associated with an excellent girth profile after inflation. Placement of a malleable (semi-rigid, non-inflatable) device is not associated with any girth increase. Penile girth enhancement using fat tissue has stopped being used by rational and scrupulous surgeons as it does not work. Penile widening may be accomplished using subcutaneous placement of strips of tissue or grafts but as far as I know there is no published data on how many men find the results satisfactory (but you will get many surgeons who do this saying that it is a great approach!). The core credo in my practice in men with PD is giving them realistic expectations and you would need to go into any such surgery with your eyes wide open.close

By the Lue procedure I presume you mean the 16-dot plication technique. This is an excellent procedure for men with low degrees of uniplanar curvature without indentations or hour-glass deformity. It is of course associated with penile shortening as we are shortening the long side of the penis with this operation. Plaque incision and grafting is an excellent procedure for younger men, with multiplanar curvature or those with severe degrees of curvature who would experience too much length loss with a plication procedure. It has as a complication the development of worsening of erectile problems. In some cases, plaque incision and grafting may not correct the curvature completely and a plication procedure needs to be done in combination. This of course will possibly result in both complications, shortening and erectile dysfunction. Where possible I avoid combination procedures for this reason.close

It does not appear to be any advantage to use of the laser knife or any other laser treatment for Peyronie's disease. Studies have been done in the past which actually showed that the results following laser surgery on the plaque resulted in a much higher rate of postoperative erectile dysfunction. Use of the laser also adds unnecessary expense, and is no less invasive than a standard surgery.close

There may be ongoing studies using shockwave therapy for Peyronie's disease, but it is not yet approved and it is unlikely to be approved as the majority of published studies and ongoing reports have not shown benefit following the use of shockwave therapy for Peyronie's disease. A large placebo-controlled trial from Germany presented at the 2006 and 2007 American Urological Association Meeting showed no benefit with regard to curvature or sexual function. It is my opinion and that of many other experts that shockwave therapy should no longer be offered for Peyronie's disease.close

Plaque incision or partial excision surgery is indicated for men who have more severe curvature, in excess of 60-70 degrees with or without severe indentation or hourglass effect causing a hinge or buckling effect. In these circumstances, an incision is made through the area of maximum curvature, or if there is a large indentation, this area of the plaque will be excised (removed). The defect created within the tunica albuginea must be filled with a graft so that the erectile bodies will trap the blood and remain pressurized for erection. A variety of grafts have been used over the years including dermis, vein, temporalis fascia, fasia lata, tunica vaginalis and now off-the-shelf grafts are being used including pericardial grafts from humans and bovine sources as well as small intestinal serosa from the pig. All of these grafts have been shown to work in a similar fashion. The key to success is patient selection and surgical technique. This is not an operation which is recommended to be done by a surgeon who performs this type of procedure only once to twice per year. The reported success with straightening is in the 90%+ range with the primary side-effect being diminished rigidity which occurs in anywhere from 5-30% of patients depending on their pre-operative erectile status.close

Most authorities no longer remove the entire plaque but rather incise (cut) and then place a graft in the gap left behind. Two of the most commonly used grafts today are cadaveric pericardium (Tutoplast) and intestinal submucosa (Surgisis). There is no evidence to show that one is better than the other. In the hands of an experienced surgeon, both result in excellent straightening of the penis and in the vast majority of cases preservation of penile length. While some men report improved length, my measurements after surgery have not shown any major improvement in length. Recently we have started using penile extenders after plaque incision and grafting. The biggest problem with this procedure is that you have to be prepared for a 25% chance of reduced erection hardness after surgery.close

When Peyronie's disease is recognized and requires surgical correction, the great majority of insurance companies will cover the cost for the surgery. Fees vary by region and surgeon, but I have seen surgeon charges ranging from $1500.00 to $9000.00 for penile straightening with plication or grafting.close

The Nesbit procedure is used in general to describe a variety of plication operations. This means that if the penis is curved in one direction, the tunica is shortened on the opposite side. As an example, if the penis is curved downward, then shortening would occur on the top surface of the penis so that the top and bottom aspects of the penis would then become equal, thereby straightening the penis. There are a variety of plication operations first described by Nesbit in the 1960s, but other approaches are used which avoid excising tissue and simply using suture with incision to shorten the longer aspect. Nesbit type procedures are performed worldwide and are certainly performed by many centers in Canada. Prices will vary depending on physician and insurance coverage, but by-and-large it can be performed as an out-patient procedure typically taking about 1 hour and will cost anywhere from $1,500-$4,000 for the surgeons fee with additional charges for anesthesia and the operating room.close

Your statement is true that younger men tend to heal better and have better underlying erectile function. The experts on Peyronie's disease would likely not be reluctant to perform surgical correction on the young man (under 40 years old) with stable Peyronie's disease who has a curvature which is interfering with sexual activity. Should your experience be that you are not finding success with your local physician, you might check out the physician referral region on this website as there are surely physicians there who will operate on young men with stable Peyronie's disease.close

It seems that you have a rather severe degree of Peyronie's disease with a 90-degree downward or ventral bend. The fact that you have a hinge-effect suggests that there may also be some indentation which is destabilizing the penile shaft resulting in the ability to flex the penis. If you are sexually functional at this time and it is not causing you or your partner any difficulty, then no treatment is necessary. On the other hand, because the curvature is downward or ventral it is very difficult to get any injectable drug into the plaque to result in benefit. My experience with verapamil injections in patients with advanced ventral curvature has resulted in very little benefit. In addition, surgery may be an option, but in men with advanced ventral curvatures who undergo incision and grafting, there is a significant risk of post-operative erectile dysfunction. Colchicine has not been shown to be very beneficial, nor has any other oral treatment for such severe Peyronie's disease. I therefore would not recommend oral therapy as a likely benefit for you. Colchicine is not yet available and it is still some time before phase two clinical trials will begin. It is possible that patients with ventral curves will be excluded from the initial trials because of the overall poor response rate with downward curvatures. Therefore, I think surgery is going to be your best option should you want to correct the deformity. You will certainly need more advanced evaluation to determine the quality of your penile blood flow and the actual location of the plaque to determine whether the plication operation would make sense for you or whether a penile prosthesis would be indicated. I would caution you if a grafting procedure is recommended, that the risk of post-operative erectile dysfunction is around 50% even in those men who have good pre-operative rigidity.close

The surgeries are designed to correct the erect deformity. Irregularities in the flaccid condition are not felt to be clinically significant and may not be correctable as the tissues are soft and naturally take on different shapes. All men have some irregularities in the shape of the penis such as draping to one side or another or even kinked a bit. The key is that when the penis is erect that it is functionally straight enough to allow penetrative sexual activity. You should also be aware that no man has a perfectly straight penis. Experts believe that curvature in any direction up to 30 degrees will typically not interfere with sex.close

Dr. Levine answers: Penile plication is the preferred surgical approach for straightening the penis, for congenital curvature. The sensory nerves supplying the shaft and the head of the penis run on the top or dorsal surface of the penis. Therefore, if you had a downward curve, it is likely those nerves had to be mobilized. Typically when nerves are moved or slightly damaged, there will be a period of numbness which will fill in over time. Nerves heal very slowly and therefore, it may take 3-12 months to recover complete sensation. If the nerves were completely damaged, then the likelihood of complete recovery of nerve sensation is reduced, but still can fill in to provide satisfactory sexual sensation due to ingrowth of nerves from other areas.close

Dr. Levine answers: This type of curvature is best treated with surgery. The type of surgery depends upon several factors. If there is Peyronie's disease which has caused substantial shortening, or the penis is already short then there is likely to be further shortening when correcting a downward (ventral) curvature. The amount of shortening depends upon the degree of curvature. The more severe the curvature, the greater the amount of shortening. Studies have shown that the amount of length loss in men with curvature of less than 60 degrees tends to the in 1-1½ cm range, but when it is in excess of 60 degrees, more curvature is possible. On the other hand if the curvature is severe (more than 70) and a grafting procedure is performed to correct it, there is a reported higher risk of erectile dysfunction, which approaches 50% of men undergoing grafting for downward curvature. For men with congenital downward curvature, these men typically have increased elasticity and long penises. In these patients, I always recommend a plication operation instead of a grafting procedure. This is because the degree of shortening in the man with congenital curvature tends to be less bothersome, and there is a substantially lower rate of postoperative erectile dysfunction with the plication procedure. For men who have Peyronie's disease, severe ventral curvature and borderline erectile dysfunction, it is best to consider placement of a penile prosthesis with simultaneous straightening of the penis. In this circumstance, the prosthesis will support the straightening and allow satisfactory postoperative rigidity for sex.close

Dr. Levine answers: The question is clearly a good one and important to recognize that the indications for surgical correction depend upon several factors, and first and most importantly that the deformity of the penis interferes with sexual activity enough that it is difficult or impossible to perform penetrative sex. With this in mind, several protocols have been developed over the last decade, which have all agreed to the following. If the penile deformity is not severe (less than 60-70 degrees), and there is no significant indentation, hourglass deformity or hinge effect, then penile straightening with a plication operation is indicated. The Nesbit is one of the first plication operations and there are many variants, and the results are pretty much the same with a high rate of satisfactory straightening and very low worsening of erectile function. There is one concern with any plication operation including the Nesbit, which includes possible shortening of the penis. This is why we limit the men to be offered type of procedures so that with less than 70 degrees of curvature, as this will less rule and should not result in substantial loss of length. This has been confirmed in a recent publication in the January, Journal of Urology by Laurence Levine, MD and associates. On the other hand, when a grafting procedure would be indicated when the curvature is severe (exceeding 70 degrees), and/or there is substantial narrowing which results in an unstable penis, which is also called a hinge effect. In this circumstance because of the greater severity of this problem, a more advanced operation is indicated. In this circumstance, the area of maximum scarring is either incised or excised, and then the defected is covered with a graft of which there is a variety available today. The risk of penile shortening is much less with the grafting procedure, but the rate of erectile dysfunction following grafting is higher because of the exposure of the underlying vascular tissue and the potential for postoperative venous leakage. Studies have been done to look at who would be most at risk for developing erectile dysfunction following a grafting procedure, and for the most part these studies have revealed that the quality of erectile function preoperatively can help predict postoperative results. That is to say men who have some compromise to their erections preoperatively are not likely to get better and may get worse. Therefore, it is the opinion of most experts that the grafting procedure be performed in men who have excellent quality rigidity, but severe deformity. In this circumstance, reported erectile dysfunction after surgery ranges from 5-15% in individuals undergoing this operation. It is also for this reason that I feel strongly that experts in the field of penile reconstruction for Peyronie's disease perform the grafting procedure, as this is delicate surgery that requires experienced hands. The Nesbit procedure or other plication operations are less risky, and therefore may be performed by any urologist who is comfortable with this technique. It would also be useful to note that the goal of penile straightening procedures is to create a functionally straight penis. This is defined as residual curve of less than 20 degrees which should not interfere with penetrative sex. This type of curvature is best treated with surgery. The type of surgery depends upon several factors. If there is Peyronie's disease which has caused substantial shortening, or the penis is already short then there is likely to be further shortening when correcting a downward (ventral) curvature. The amount of shortening depends upon the degree of curvature. The more severe the curvature, the greater the amount of shortening. Studies have shown that the amount of length loss in men with curvature of less than 60 degrees tends to the in 1-1½ cm range, but when it is in excess of 60 degrees, more curvature is possible. On the other hand if the curvature is severe (more than 70 degrees) and a grafting procedure is performed to correct it, there is a reported higher risk of erectile dysfunction, which approaches 50% of men undergoing grafting for downward curvature. For men with congenital downward curvature, these men typically have increased elasticity and long penises. In these patients, I always recommend a plication operation instead of a grafting procedure. This is because the degree of shortening in the man with congenital curvature tends to be less bothersome, and there is a substantially lower rate of postoperative erectile dysfunction with the plication procedure. For men who have Peyronie's disease, severe ventral curvature and borderline erectile dysfunction, it is best to consider placement of a penile prosthesis with simultaneous straightening of the penis. In this circumstance, the prosthesis will support the straightening and allow satisfactory postoperative rigidity for sex.close

Dr. Levine answers: Loss of length depends upon the direction of curvature and the degree of curvature particularly in performing a plication operation such as the Nesbit procedure. In this operation, the loss of length has been reported to range from 0-5 cm. In a published report from January 2006 in the Journal of Urology, Greenfield et al reported their experience in men with Peyronie's and congenital curvature where there was very little loss of length if the curvature was lateral or upward whereas if it was downward and exceeded 60 degrees, length loss could be 2.5 to 5 cm. The risk of not undergoing the plication operation for the man who has relatively mild to moderate curvature, is that there is an increased risk of erectile dysfunction when performing a grafting procedure. The grafting procedure should be reserved primarily for those men with severe curvature and excellent rigidity.close

Dr. Levine answers: The best case scenario is clearly satisfactory functional straightening of the penis to less than 20 degrees, preservation of sensation, length and erectile capacity. In men who have good erections preoperatively, 95% can expect this type of result. In men who have borderline erections, upwards of 30% will have worsening of their erectile capacity after a grafting procedure. The overall worse case scenario in a man with severe curvature would be inadequate straightening and correction of girth, shortening, loss of sensation and erectile dysfunction. Thankfully, the experts in the field who have published on the incision and grafting technique have reported the worse case scenario in the very rare patient as it is important to select patients carefully for this operation.close

Dr. Mulhall answers: Surgery is typically reserved for men who meet one or more of the following criteria (i) difficulty or inability to achieve penetration (ii) pain for himself or his partner during attempts at penetration (iii) psychological distress at the presence of penile deformity and (iv) stable plaque that will not improve or worsen in the future (this typically means that a man should have Peyronie's disease for at least 12 months). Generally speaking, curvatures of more than 45 degrees dorsal (upward) or lateral (right or left) lead to great difficulty penetrating. Curvatures of more than 30 degrees ventral (downward) lead to difficulty with penetration. Thus, there are many men who have 30 degrees of penile curvature in a dorsal direction who can penetrate with ease. 2 other factors impact upon the ability of a man with penile curvature to penetrate. The first is penile rigidity (hardness); some men with curvature are capable of penetration until they develop erectile dysfunction (loss of penile rigidity) and only then do they have difficulty with penetration. One of the treatments for such men is to use medications to increase their penile rigidity before considering surgery. The other factor that can make a man with minimal curvature have difficulty penetrating is the presence of "waisting" or "hinge-effect" at the site of the curvature. This associated deformity can lead to great instability where the penis buckles during attempts at penetration. There are 3 types of surgery used in the correction of penile deformity. No one procedure is correct for every Peyronie's disease patient. A Peyronie's disease surgeon should be capable of performing all 3 operations (see Dr. Mulhall’s article on How to Choose a Physician for Peyronie’s Disease). The 3 procedures are (i) plication (also known as corporoplasty) procedures. There are a variety of modifications of this procedure including Nesbit surgery, the Essed-Schroeder technique and the Yacchia procedure (ii) plaque incision and grafting procedures and (iii) penile prosthesis (implant) surgery. For a surgeon there are generally 4 factors that help him/her decide which operation is best for the patient (i) the nature of the deformity (is it a simple curvature or a curvature associated with hinge-effect?) (ii) the magnitude of the deformity (is it 30 degrees or 90 degrees) (iii) the penile length (as corporoplasty surgery may lead to loss of penile length, this is a significant factor in deciding the appropriate operation) and (iv) erectile function (the presence of ED may impact significantly on the choice of operation). Most authorities recommend that all men undergoing penile reconstructive surgery (not necessarily penile implant surgery) have an erectile function test (penile ultrasound, cavernosometry) prior to undergoing such surgery. For the patient above who posted the question, at 5 years into his condition his deformity is stable, he admits to being able to penetrate which is somewhat surprising given his 60 degrees of curvature. Thus, he does not HAVE to have surgery to continue having sexual intercourse. He must decide if his relations are satisfactory. If yes, then he may continue to have relations in his current state. If not, then he should have a comprehensive discussion with a Peyronie's disease surgeon about the various options as listed above.close

This is a very important question and I am delighted that you are concerned enough to address it in this website. Peyronie's disease has been known for many years, but has recently been demonstrated in a proper trial to result in significant depression in the affected male. This is clearly because the penis is an important organ for men and for some, it truly defines them. Any alteration in the penis in terms of physical appearance or function can result in states of anxiety and mild to severe depression. Certainly, ignoring this problem will not help your husband and instead, I would recommend that you encourage him to see a qualified physician with experience in Peyronie's disease who may be able to offer treatment to stabilize or possibly resolve the problem. What is important to remember is that the goal of the physician is to prevent progression of the Peyronie's disease and also to try to restore function, but not necessarily to restore the appearance and condition of the penis to how it was before the Peyronie's disease occurred. Usually there will be some residual loss of length, possibly some residual curvature and maybe even some erectile dysfunction. Support from spouses, sexual partners and family will be very important to the successful recovery of the affected man. Occasionally the depression can be so severe that counseling, sex therapy or even psychiatric care may be necessary and beneficial.close

Dr. Levine answers: The question is clearly a good one and important to recognize that the indications for surgical correction depend upon several factors, and first and most importantly that the deformity of the penis interferes with sexual activity enough that it is difficult or impossible to perform penetrative sex. With this in mind, several protocols have been developed over the last decade, which have all agreed to the following. If the penile deformity is not severe (less than 60-70 degrees), and there is no significant indentation, hourglass deformity or hinge effect, then penile straightening with a plication operation is indicated. The Nesbit is one of the first plication operations and there are many variants, and the results are pretty much the same with a high rate of satisfactory straightening and very low worsening of erectile function. There is one concern with any plication operation including the Nesbit, which includes possible shortening of the penis. This is why we limit the men to be offered type of procedures so that with less than 70 degrees of curvature, as this will less rule and should not result in substantial loss of length. This has been confirmed in a recent publication in the January, Journal of Urology by Laurence Levine, MD and associates. On the other hand, when a grafting procedure would be indicated when the curvature is severe (exceeding 70 degrees), and/or there is substantial narrowing which results in an unstable penis, which is also called a hinge effect. In this circumstance because of the greater severity of this problem, a more advanced operation is indicated. In this circumstance, the area of maximum scarring is either incised or excised, and then the defected is covered with a graft of which there is a variety available today. The risk of penile shortening is much less with the grafting procedure, but the rate of erectile dysfunction following grafting is higher because of the exposure of the underlying vascular tissue and the potential for postoperative venous leakage. Studies have been done to look at who would be most at risk for developing erectile dysfunction following a grafting procedure, and for the most part these studies have revealed that the quality of erectile function preoperatively can help predict postoperative results. That is to say men who have some compromise to their erections preoperatively are not likely to get better and may get worse. Therefore, it is the opinion of most experts that the grafting procedure be performed in men who have excellent quality rigidity, but severe deformity. In this circumstance, reported erectile dysfunction after surgery ranges from 5-15% in individuals undergoing this operation. It is also for this reason that I feel strongly that experts in the field of penile reconstruction for Peyronie's disease perform the grafting procedure, as this is delicate surgery that requires experienced hands. The Nesbit procedure or other plication operations are less risky, and therefore may be performed by any Urologist who is comfortable with this technique. It would also be useful to note that the goal of penile straightening procedures is to create a functionally straight penis. This is defined as residual curve of less than 20 degrees which should not interfere with penetrative sex.close

Dr. Levine answers: The tunica vaginalis of the testicle has been used historically for correction of penile deformities as an autogenous graft material. This means the graft is taken from the patient's own body. This does not need to be taken from a man who has an enlarged fluid filled sac around the testicle, known as a hydrocele. Unfortunately the results with the tunica vaginalis grafting have not been particularly successful in that the graft tends to contract. I have not used a tunica vaginalis graft in over 10 years because at least 50% of my previous postoperatively.close

Dr. Levine answers: Pericardial graft tissue has been employed from both bovine (cow) tissue and from human cadaver donors. The pericardium is the jacket that surrounds the heart. This has been found to be a useful tissue as it has many of the qualities of normal human tunica albuginea of the penis. Pericardial grafts have been used in many different sites of the body including the ear, eye, heart, for hernia repair and genitourinary tract repair, as well. The human pericardial graft that I have used for penile straightening procedures is the so-called Tutoplast processed graft, which undergoes a four step procedure to eradicate all cellular material, bacteria, viral elements and is also reported to eradicate prions (subviral particles). Therefore, the graft is free of all organic elements except for the collagen which provides the strength for the graft. It is thin, strong and easy to use in the operating room. In my experience, the pericardial graft has shortened operating time by as much as 1.5 to 2 hours when doing a penile straightening procedure where grafting is necessary. As a result, the cost to the patient is reduced as operating room time is quite expensive and although the graft does add some expense, the savings in reduced operating time makes up for the price of the graft. So far it has been reported that Tutoplast (the human processed pericardial graft) has been used in over one million operations throughout the body with no reported transmitted infectious diseases. I personally have not used Bovine pericardial tissue, but I am aware of the reports on its use and the results have also been satisfactory. Many other grafts have been used for penile straightening procedures including vein, dermis (skin), temporalis fascia (found behind the ear), synthetic material, (which I do not recommend) including Gortex, and Dacron as well as porcine (pig)intestinal tissue, known as SIS. My limited experience with Alloderm (a human cadaver skin graft) has been quite unsatisfactory as there has been extensive contraction of the graft, and therefore I have stopped using this product. Overall in my opinion, other than not recommending the use of the synthetic grafts and Alloderm, there is no ideal graft and there is no evidence that one is significantly better than the other. The key factor, in my opinion, is the experience and skill of the surgeon in performing these more complex surgical reconstructions.close

Dr. Levine answers: Penile implant technology has improved remarkably since the first inflatable devices of the early 1970s. The improvements were primarily to make the devices more reliable and less likely to mechanically fail. Various other modifications have been made to try to optimize the sizing of the prosthesis to prevent shortening and to provide the optimum length and girth to the penis. Unfortunately one can not make the penis longer or wider with a prosthesis as the tunica albuginea limits the length and girth that the penis can expand. When an implanted prosthesis is too large, it will simply buckle, create serpentine deformities of the penis or kinks and knuckles within the prosthetic cylinders. The key to placing a penile prosthetic is proper sizing. There are therapies that have been offered to potentially lengthen the penis using such things as vacuum devices or weights; these have not been demonstrated to result in any true lengthening of the penis without potential compromise in girth, and may indeed cause internal damage. Certainly the quest for making a larger penis remains, and the individual who discovers the key to this will certainly be able to write their own ticket to success.close

PD is a progressive scarring disorder which does tend to stabilize anywhere from 6 months to 2 years after onset. During the progressive active phase, scar will develop and then will cause progressive contraction. This may result in the noted deformities including curvature, shortening and a variety of indentations resulting in loss of girth or hinging. Typically the disorder will stabilized with time, but it is best that when the disease is first recognized, medical therapy is considered using oral therapy, possibly injection therapy or iontophoresis and recently showing some benefit is external traction therapy. All of these approaches try to accelerate stabilization and possibly recover a more normal shape. With regard to laser surgery, there have been no studies which have demonstrated any true beneficial effect. In the past lasers have been used specifically on Peyronie's plaque and on calcified plaque and in these studies the scar tissue was actually made worse with exaggerated deformity as well. Therefore, at this point topical or surgical use of laser is not indicated for Peyronie's disease.close

Dr. Mulhall answers: It is not uncommon for physicians who do not see a lot of Peyronie's disease patients and who do very little Peyronie's disease surgery to have negative thoughts about this surgery. In the hands of an expert surgeon and after a comprehensive discussion giving the patient realistic expectations, many men proceed with such surgery and have a safe and successful outcome. The new procedure that you are probably referring to has been performed by Dr. Gerald Brock in Canada. In this procedure, an incision is made in the tunica and the plaque is incised from the inside. There is no long-term data on the safety and effectiveness of this procedure. At this time, most authorities would consider this procedure investigational.close

Dr. Levine answers: At this point there is no evidence that anyone is recommending a penile transplant. It is certainly a procedure which is technically possible, but with potential significant complications and the need for lifelong immunosuppression to reduce rejection. In men who have had penile amputation and replantation of their own penis, erectile dysfunction and scarring is common. Therefore, it does not appear to be a reasonable option for treatment of Peyronie's disease at this time.close

Dr. Levine answers: Most men have some degree of curvature to their erection and typically a 30-degree or less curvature in any direction should not interfere with intercourse or cause you or your partner discomfort. If your penis always has been curved, this may be a congenital process. On the other hand, if the curvature has occurred more acutely and is associated with pain or a palpable lump in the penis, this is likely Peyronie's disease and should be evaluated by an urologist. Fifty percent of the time, Peyronie's disease will progress, 40% will stay the same, and 10% will have spontaneous resolution. I am not familiar with any expert with Peyronie's disease in Pakistan. It would be best to contact the Department of Urology at the local university medical center, as an expert would be most likely found in this environment.close

Dr. Levine answers: If the penis has always had a curvature, then it is likely this is a congenital abnormality known as chordee. If it is interfering with penetrative sex, then you should be seen by a urologist who is capable of surgically repairing this problem. If it is a new onset of deformity which interferes with penetrative sex, then it would also be reasonable to see a urologist first as they are most likely to be familiar with Peyronie's disease and could offer the best advice.close

Dr. Levine answers: If complete insertion of the penis cannot be obtained, and it is not causing the person or his partner any discomfort, then they can certainly make do with partial insertion. Certainly if one is hoping to impregnate the partner then it is best to have full penetration to deliver the seminal fluid and sperm into the depths of the vagina.close

Dr. Mulhall answers: It is estimated that up to three quarters of men with Peyronie's disease have some psychological disturbance as a result of their condition. The commonest of these is depression. However, very few medical studies have been conducted assessing this. Dr. Mulhall is leading an international study to assess this by administering questionnaires to men when they present with Peyronie's disease to answer the question are these men depressed and is their quality of life impaired. For any physician who manages a lot of Peyronie's disease patients, it is clear that there is a significant negative impact upon their general quality of life, self-confidence and self-esteem. Finally, the impact of man's Peyronie's disease on his partner's mental health must not be underestimated. We receive at this website many questions and pleas from partners asking for information and support. The exact incidence of ED in men with Peyronie's disease is not well known. There is little doubt that Peyronie's disease can cause erection problems and this can occur in 3 different ways (1) Peyronie's disease has its commonest incidence in middle age to older men and therefore many patients who present for evaluation of Peyronie's disease have a variety of medical condition that are associated with ED such as hypertension, cholesterol issues, CAD and diabetes. Therefore it is likely that many men with combined ED and Peyronie's disease have their erection problems as a result of vascular disease unrelated to their Peyronie's disease (2) there are many men with Peyronie's disease, especially the younger patients who are so psychologically perturbed by their Peyronie's disease and the penile deformity that when they obtain an erection there is such a massive release of adrenaline that their erections are impaired (adrenaline is an anti-erection chemical) (3) in some men the presence of the plaque can cause problems with erectile function. The plaque is a scar and it may extend into the underlying erectile tissue (the smooth muscle within the corpora cavernosa) causing damage to this tissue. This in turn can lead to a condition called venous leak (indeed, to be more specific this may lead to site specific leak, that is leakage at the site of the plaque). Another means by which the Peyronie's disease may lead to ED is distal softening that is that the penis is less rigid beyond the plaque than it is behind the plaque. Finally, some men have combined curvature and waisting or shaft narrowing which may cause instability of the penis even at maximum erection, that is that the penis bends and buckles at the point of the plaque (this is also known as the hinge effect). A patient with combined Peyronie's disease and ED may benefit form a vascular evaluation of the penis (such as a penile ultrasound) to define the cause of their ED.close

Dr. Levine answers: There are potentially quite a few factors which could contribute to this problem. With regard to the configuration of the penis, it may be that he has a congenital curvature resulting in the cobra shape or he may have acquired some scarring, particularly if rather vigorous intercourse and/or masturbation is used to accomplish orgasm. He may also have Peyronie's disease. It is doubtful that the shape of the penis is responsible for the difficulty with orgasm. Delayed orgasm is a very complex problem and not well understood. The most common etiology is a low testosterone and/or a sensory deficit of the penis. Sensory deficits can occur as a result of underlying medical problems such as diabetes or neurological disorders including stroke and multiple sclerosis. Most frequently though, there is no clear reason for the delayed orgasm. Occasionally this can be a behavioral problem, meaning that the man has conditioned his sexual response to a certain type of stimulation and if this is not achieved, then orgasm will not occur. Basically, the best advice would be to see a physician who has a strong interest in sexual dysfunction to do a proper evaluation and consider evaluation by a sex therapist as well.close

Dr. Levine answers: This presentation sounds more like a congenital curvature of the penis, which is not associated with scarring and is typically a process, which results in a downward curvature known as chordee. If the curvature is significantly downward, it can make penetrative sex difficult to impossible and occasionally quite uncomfortable for the female partner. Clearly the best approach for you would be to see a Urologist familiar with this process where a surgical straightening of the penis is the only option for treatment offering the most rapid and reliable results.close

This question has come up before and was addressed during another Q and A session. It certainly is timely to address it again. There has been discussion with leading researchers. in the field of tissue regeneration with respect to Peyronie's disease. The concept would be using some kind of matrix tissue into which either tunica stem cells or a combination of fibroblasts which produce the collagen of the tunic with endothelial cells which are vascular cells which grow into the matrix. Another concept is to generate a complete piece of tunic in the laboratory which could then be directly implanted into the patient during penile reconstructive surgery. Although there is much progress being made with tissue regeneration, at this time we are not aware of an active research specifically for Peyronie's disease. It is likely in time this will emerge. But frankly it appears that the current grafts, including vein, processed cadaveric pericardial tissue, and porcine small intestinal sub-mucosa (sis) are working well. The primary concern is not that the graft does not take adequately, but that the graft may be in part may be responsible for post operative erectile dysfunction. It is my opinion that the primary reason for the post-operative ED is patient selection issue having most to do with the underlying vascular health of the man and not the type of graft used.close

At this time there are no ongoing studies using stem cell therapy for treating Peyronie's disease. Some of the initial work being done for erectile dysfunction is just being presented at our society meetings. It is likely that some day there will be tissue engineering techniques which will emerge and potentially act as a tissue which can replace the diseased tunica which is the tissue affected by PD. At this time there are off-the-shelf grafts as well as tissues from the patient which can be used to correct deformity when incision and grafting is necessary.close

There are exciting developments occurring within the field of regenerative medicine. Some laboratories have actually been working on developing component parts or even a complete penis. So far, all of this has been on animal models only and to my knowledge there are no human trials on-going. Should you want to check out what is happening in this field, the best site may be the Wake Forest University Department of Urology website.close

Dr. Levine answers: There is an ongoing research at Bowman Gray Medical Center on a variety of different tissues, which may be developed for future transplantation. This includes the lining of the urethra, the bladder and possibly even the corporeal tissues of the penis. A full artificial penis has not been developed in the lab, has not yet been reported, but, who knows? It may be on the distant horizon.close

Dr. Mulhall answers: Stem cell research is the sexy topic of the beginning of the 21st century and it is difficult to find an area in medicine that would not benefit from it, if it is proven to be of benefit in tissue regeneration. There are no studies even in laboratory settings that have looked at its use in Peyronie's disease. One of the great challenges in Peyronie's disease management is to prevent the plaque formation rather than reverse it once it has happened which is probably more difficult than its prevention. Much of the basic research that is ongoing at Cornell Medical Center in NYC, UCLA in Los Angeles, UCSF in San Francisco, Rush University in Chicago and Tulane in New Orleans is aimed at understanding the early steps in the development of plaque tissue so that it can be prevented.close