Penis shape may differ from one person to another. Slight inclination of the penis towards right or left when erected is normal. This is a normal condition as long as it’s not too much inclined. Penis curvature is a common aesthetical problem in terms of sexual intercourse. It has two different types. It can be both inherent (congenital penile curvature) and can be subsequent (Peyronie’s).


  • A.) PEYRONIE’S DISEASE
    Although its reasons aren’t known completely, the most common reason is the trauma during sexual intercourse. Laceration in the tunic surrounding the corpus cavernous (structure maintaining the blood flow in penis) called tunuca albuginea occurs as a result of these traumas and fibrosis plaque is formed during the healing period of the tunic. Fibrosis plaque is typically formed on penis dorsum and sometimes on the side of penis. This fibrosis plaque formed causes penile curvature during erection. As a result it may cause asymmetry or curvature of the penis towards the front, back or to the side.

    Studies suggest that gene activation and connective tissu disorders associated with healing also cause Peyronie’s disease. It’s claimed that vitamin E deficiency, long-term use of some medications such as propanol, metotrexat, diabetes, gout, long-term smoking and surgical operations on urinary tract may also cause the disease.



In Peyronie’s, sometimes the curvature might be too obvious, can make the sexual intercourse impossible and this disturbs the partners. Mass and curvature in penis isn’t seen in every male individual and they don’t have the same severity. It’s a progressive disease. At first it starts with pain during erection and this pain goes away without any treatments. When the person starts to feel the rigid plaques in his penis, he also notices the curvature and angling during erection. Therefore, if there is a feeling of pain or mass in the penis, you should immediately see a doctor without any suspicion or shame. Because this may affect your sexual life.


Diagnosis of Peyronie’s Disease
Anamnesis and physical examination are enough for the diagnosis of Peyronie’s disease. Plaque would be palpable. While the history is obtained; occurrence time and way (chronic or acute), progress pattern of the disease, medications used and habits are evaluated. In sexual history; any possible difficulties of the patient for erection is questioned. Ultrasound may help determining the exact size and location of the plaque.



How is Peyronie's treated? When does it require surgery?

It’s necessary to know the stage of the disease first for the treatment. The disease has two stages. During the first one, instabile period which is called “active phase, acute inflammation stage”, the patient feels pain during erection. There is a plaque in the penis and a slight curvature is in question. This stage continues around 12-18 months.

In the second and stabile period called “chronic inflammation stage”, the disease is certain. This is the period when an obvious curvature on the penis is seen, problems regarding erection occur and plaque size doesn’t change.

Knowing the stage of the disease is significant in terms of treatment selection. Because it has been reported that in some of the patients, the symptoms can disappear by itself and in 50% of them the disease progressed.

If the patients applying with the symptoms of Peyronie’s are in their active period, mostly oral medications and injection treatments to prevent the progress of curvature are preferred. These patients move to the chronic stage approximately in 1 year. In the patients whose pain disappeared during the chronic period, the only reasons for treatment is the difficulty in sexual life due to the fixed angle and that the curvature creates a problem between the partners. Preferred treatment during this period is surgery.

 
1. Oral Medication:
If the disease is in the instabile period, plaque is small, there is a slight penile curvature, there is no pain and there are no sexual dysfunctions, medication can be recommended. Medication is preferred for the patients with early stage. But it’s a fact that they aren’t so successful in treating. The purpose is to prevent the progress, reduce the pain and keep the erection capacity.

Vitamin E: It’s one of the most popular treatment for the early stage disease. Because there is almost no side effect, and its use is easy and cheap. It’s believed that it effects by reducing the production of molecules that are held responsible for the forming of rigid plaque structure on the penile tissue and called free oxygen radicals.
POTABA (Potassium Para-Aminobenzoate): It’s a substance preventing the formation of abnormal fibrotic tissue. It should be used for a period between 3 and 6 months. It’s also a medication that can have side effects on gastro-intestinal system and is expensive.

Colchicine: It suppresses the inflammatory response in the tissue, reduces collagen production and increases their subversion. It has side effects on gastro-intestinal system and may cause diarrhea. .
Tamoxifen: It’s been shown that this non-steroid anti oestrogen medication reduces the fibrosis by suppressing inflammation and scar tissue formation. It has side effects on gastro-intestinal system and may cause hair loss.

2. Medications Applied in the Plaque

In this type of treatment, medication is directly inject in the penile plaque and is an alternative to the oral treatment. This is called intralesional injection. It’s a more popular treatment option among the male individuals who don’t want to have operation or are in the early stage of the disease.

-Clostridial collagenase (collagenase clostridium) injection: Significant elimination of curvature angle, plaque width and length has been observed during intrelesional treatment. (This medication is not used in our country yet.)

Various alternatives techniques such as cortisone injection into the plaque, shock waves from outside the body (debatable for fixing the curvature and reducing plaque size. However, may reduce the pain.), penile traction and vacuum devices (in order to prevent the penis from shortening in size) are also used.


Surgical Treatments

Surgical treatment is recommended in the cases where the scleroma in the penis doesn’t regress and difficulty during sexual intercourse due to deformation is present.

It’s applied during the stabile period of the disease and on the patients who can’t benefit from the medications. Additionally, if the curvature is more than 45 degrees, patient has erection disorder and there is certain shortening in the size of penis, then the surgical treatment is considered first.

Surgical treatment of Peyronie’s disease includes fixing the penile curvature surgically and placing penile implant for the patients with erection problem along with Peyronie’s. Conditions which are determined as surgical treatment criteria are as follows;

• Severe penile curvature existed for more than one year,
• Penile curvature or erection problem progresses and is stabile for the last 3 months,
• Presence of penile curvature in a level affecting sexual intercourse
• Advanced shortening of penis.

Penile implant is conducted typically on patients who have erection problems along with Peyronie’s and have vascular failure.

 
Penile Implant Operations

It’s conducted on patients who have erection problems along with Peyronie’s disease. Only implant would be enough for the patients whose penile curvature is a slight one. If this doesn’t fix the curvature, an additional operation to cut the plaque and cover the area depending on the size of plaque might be required.

Today, in developed countries, typically 3 part inflatable penile implants are preferred. After the procedure of 3 part penile implant, satisfaction of the patient and his sexual partner can go up to 90%.

Operations can be conducted under general or regional (spinal/epidural) anaesthesia.

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B. ) CONGENITAL PENILE CURVATURE (INHERENT)

While the patients apply with the complaints regarding difficulty in sexual intercourse, having sexual intercourse in some specific positions and pain in their or their partner’s body during sexual intercourse, some of the patients apply with the idea that the curvature may affect their sexual life without experiencing any problems. Diagnosis is established by observing the curvature through physical examination during erection (or its photo is requested from the patient)

Congenital penile curvature is the curvature of the penis on one side inherently. This penis is typically normal or longer than usual. Patients apply to us for the treatment especially in their 20s when they become sexually active and they notice.

If the curvature is more than 30 degrees and is preventing sexual intercourse or if the appearance is disturbing even though there are no functional problems, then this curvature is corrected.

Correction operations are generally conducted by shortening the longer (convex) side since the penis is long. This operation is conducted under general or spinal anesthesia. Since the penile skin is opened through the foreskin area, it doesn’t leave any marks or scars. The patient can be released on the same day with the operation and can go back to his routine the next day. For the healing of the scars, patient shouldn’t have any sexual intercourse for a period between 4-6 weeks.

 

© 2016 - Op. Dr. Cem ÖZLÜK