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Treating Peyronie's Disease

Treating Peyronie's Disease
Over the years, a wide variety of medications have been used to treat Peyronie’s disease. Some patients have benefitted, while others have found their medications seemed to make little difference. This variation in treatment outcome and the resulting lack of consensus regarding the drug(s) of choice reflects in part an uncertainty with strategy.
While doctors can’t say with precision what causes the disorder in each individual case, there does seem to be a common disease-producing process in all men. Yet where, in this complex spectrum extending from early wound healing to late scar formation, do we intervene with medications? This question remains a topic of clinical research.

In general, changes in tissue elasticity that accompany the inflammation of early Peyronie’s disease are reversible, whereas the loss of elasticity associated with the end-stage scarring characteristic of the later illness is not. Since it is a consequence of local change in elasticity, bending responds best to medical therapy in the early stage, a period that generally lasts about six months.

In order to evaluate medical treatments, we should know how a case of Peyronie’s disease evolves on its own, in the absence of therapy. Understanding this so-called natural history of the disease provides a basis for comparison, and a means for deciding when surgical intervention may be appropriate. During the intial six months of the disorder, erections can be painful. Eventually, even in the absence of treatment, the pain usually goes away. Unfortunately, bending does not always follow the same pattern. Though it may improve or resolve spontaneously in a minority of men, most untreated men with Peyronie’s disease will retain some degree of penile distortion. Most medical treatments have a success rate of about 60% in improving bending. Some factors associated with a tendency for bending to persist are: the presence of dupuytren’s contractures, the presence of heavy plaque calcification, and the presence of severe (greater than 45 degrees) curvature.

Some of the contemporary medications in use are:

VITAMIN E: this anti-oxidant has other uses in the treatment of scars, and has been employed in the treatment of Peyronie’s disease since 1945.
POTABA or potassium para amino benzoate is designated by the FDA as "possibly effective". Large doses are required, which may cause intestinal upset.
COLCHICINE is a medication used for many years in the treatment of gout. It acts against inflammation, and interferes with the manufacture of scar tissue.
VERAPAMIL is usually given by direct injection into the plaque. It also interferes with the synthesis of scar tissue precursors.
COLLAGENASE is an investigational drug that enzymatically digests scar.
Surgical Treatment:

Who should consider an operation?

Candidates for surgery should fufill four basic criteria. First and foremost is severity. The risks and expense of an operation only make sense when bending or deformity is severe enough to seriously interfere with sexual function. Secondly, natural healing or spontaneous resolution should have been given an opportunity. This is usually accomplished by deferring the decision for surgery at least twelve months from the time of onset. During this time the third criteria can be satisfied - an adequete trial of some form of medical therapy. Finally, no operation should be done on a man whose condition is changing, either for the better or worse. The best surgical outcomes are in men with stable (unchanging) condition.

What are the risks of surgery?

Unfortunately, surgery does not offer a cure for Peyronie’s disease. The scarring in men with deformity severe and persistant enough to warrant an operation represents an irreversible loss of connective tissue elasticity. Though surgical restoration of sexual function can be both effective and reliable, potential candidates need to understand the compromise inherent in this approach.

Each surgical procedure has its own specific risks. It is possible, however to review the more common risks in broader terms, as they apply to surgery for Peyronie’s disease in general. The loss of elasticity or extensibility that occurs with the disease can reduce the length of the erection, and postoperative changes can do the same. Surgery cannot completely restore the penis to its former length or condition. Some procedures shorten the penis more than others. Likewise, some surgical options are more effective in completely straightening curvature. Still, every operation carries the risk of less than perfect straightening. Due to the anatomical location of sensory nerves in the penis, surgery can interfere with skin sensation. While temporary changes in sensation are common, permanent sensory loss is rare. Finally, by disturbing either blood inflow or outflow, surgery can produce either loss of erectile rigidity (hardness) or inability to maintain an erection (impotence).

Surgical Options:

1: The Nesbit procedure

This operation, or its various modifications, corrects bending by plicating (gathering) the convex or outer side of the bend. Counteracting the relative shortage of tunica albuginea on the concave side straightens the penis, though length is reduced slightly as a consequence. Still, this procedure is less likely to cause erectile dysfunction than tissue grafting, and remains the first choice for moderate bends without associated diameter reduction. It is the best way to surgically correct congenital curvature.

2: Tissue Grafts

These procedures involve the replacement or expansion of scarred tunica albuginea with grafts of healthy tissue from another site. Originally, grafts were used to repair the defect that remained after excision of a Peyronie’s plaque. More recently, surgeons have been using grafts to expand the contracted scars (or plaque) without excising them. Though some calcified plaques still require removal, this non-excisional approach seems less disturbing to erectile function, and less likely to cause postoperative impotence. Despite this risk, grafting remain the most versatile reconstructive technique, particularly suited to correcting severe bending and/or diameter constriction.

3: Implant Surgery

Penile implants are biocompatible plastic cylinders, either solid or inflatable, that are surgically implanted into the corpora cavernosum to produce a functional erection. At one time they were a first choice for Peyronie’s patients who had trouble keeping an erection. Now, with all the effective medical remedies for erectile dysfunction, they are used less frequently. In men who don’t respond to these drugs however, they remain an excellent option