Indications for treatment of Peyronie’s disease include penile pain, curvature that prevents penetration, and/or associated erectile dysfunction. Because the exact cause of Peyronie’s disease is not known, the best form of therapy is likewise not known. Many therapies are being employed that are based on the theoretical causes of Peyronie’s disease and their effects on tissue healing. Medical therapy is most appropriate during the acute phase of Peyronie’s disease and includes oral therapy: vitamin E, colchicine, tamoxifen, and aminobenzoate potassium (Potaba) and intralesional injections: calcium-channel blockers (i.e., verapamil), steroids, and collagenases.
Vitamin E is the traditional initial treatment of choice for Peyronie’s disease. Vitamin E is an antioxidant and can decrease the build-up of harmful chemicals that can injure tissues. It is inexpensive, easy to take, and better than placebo for treating pain, and if it is taken in the appropriate dose, it causes no side effects. (A placebo is a fake medication or treatment that has no effect on the body but is often used in experimental studies to determine whether another medication or treatment has an effect.) Vitamin E has been used in doses ranging from 200 to 800 IU on a daily basis. Because of its ability to increase your risk of bleeding, you should consult with your primary care doctor before taking the higher doses.
Aminobenzoate potassium (Potaba) is another oral therapy that is used primarily for pain associated with Peyronie’s disease. The initial results of a randomized, placebo-controlled study using Potaba demonstrated a greater decrease in plaque size with Potaba compared with placebo (32.5% compared to 12.5%, respectively) and a larger decrease in penile deviation with Potaba. There are a number of drawbacks, however: unlike vitamin E, it is expensive ($1000.00 per year), has gastrointestinal side effects, and requires taking 12 g per day. Each tablet is 0.5 g, so one must therefore take four tablets six times daily, a total of 24 tablets, which can be difficult for some patients and therefore limits its use.
Tamoxifen, which decreases inflammation, has been used in men with Peyronie’s disease. In small studies, improvement in the Peyronie’s disease was noted in 55% of men treated with tamoxifen at an oral dose of 20 mg for a 3-month period. Tamoxifen tended to work better in men whose Peyronie’s disease was not long standing.
Colchicine, a medication that is used for gout, has also been used for Peyronie’s disease. Small studies have demonstrated a decrease in the size of the plaque in 20% to 50% of men who took it, and a decrease in penile curvature and improvement in the pain in almost 80% of those with pain. Side effects of colchicine include gastrointestinal upset and diarrhea. Doses used range from 0.6 mg to 1.2 mg twice a day for 3 to 5 months.
Other therapies have focused on injecting chemicals into the plaque to promote the breakdown of the plaque. Such “intralesional” therapies that have been used include collagenase and verapamil (a calcium-channel blocker), and there has been up to 42% improvement in the penile deformity with verapamil. Minimal side effects are associated with intralesional injection of verapamil.
Surgical therapy for Peyronie’s disease is not a first-line therapy and is usually performed once the disease is stable (i.e., it has been present for a year or longer). The surgical treatment of Peyronie’s disease consists of either correction of the penile curvature or placement of a penile prosthesis to straighten the penis and allow for erections in those who have penile curvature and erectile dysfunction.
Treatment of the penile curvature of Peyronie’s disease may be performed in two ways. One technique involves removal (excision) of the plaque and replacement of that segment of tunica with another piece of tissue, a graft. The advantage of this technique is that it maintains penile length. The limitations of the plaque excision and grafting technique include residual curvature or contracture, shrinkage of the graft requiring another procedure, and postoperative onset of erectile dysfunction. The occurrence of erectile dysfunction after the plaque excision and grafting may be related to damage to the underlying penile tissue during the surgery, lack of compliance of the graft, or development of a venous leak. The other technique for treating the penile curvature involves taking a tuck of the tunica on the side of the penis opposite the plaque. This technique leads to shortening of the penis; the extent of the shortening depends on the size of the tuck, called a Nesbit plication. In most cases, the small amount of shortening is not noticeable and does not affect sexual function or the ability to stand to void.
When significant penile curvature and erectile dysfunction are present, a penile prosthesis is an option that can treat both problems. At the time the prosthesis is placed, the penis is straightened by the “modeling technique.” The modeling technique involves bending of the erect penis in the direction opposite to the curvature (the prosthesis is inflated at the time). The prosthesis is inflated before the procedure is completed to ensure that the penis has been satisfactorily straightened. On rare occasions, an additional procedure, such as corporal grafting, is needed in addition to placement of the prosthesis to achieve adequate straightening. The patient can also perform some modeling after the prosthesis has been placed to straighten the penis even more. Again, this would be done with the penis erect and would involve bending it in the direction opposite to the curvature. The technique, the risks, and the satisfaction rate of prosthesis placement are discussed in the section on penile prostheses.