Peyronie's Disease: What do we know about it and how is it treated?

Mark is a 55-year-old male with a history of high blood pressure and pre-diabetes. About a year ago, he began to feel pain in his penis and noticed a curve to the left that has become progressively worse over time. Mark had been to numerous doctors over the past year and was finally diagnosed with Peyronie’s disease. His urologist wanted to ensure that Mark received a well-rounded plan of care since there is no one size fits all to address this diagnosis. Part of the plan of care included a referral to pelvic floor physical therapy in addition to medical management. 

Peyronie’s disease (PD) occurs when there is stiffening of the penis, specifically fibrosis of the tunica albuginea (the connective tissue around the corpora cavernosa which is the top area of the penis that fills with blood during an erection). There are two phases including an early or acute phase with inflammation, possibly pain, and a developing curvature, and a chronic phase with stable fibrosis or hardening.1 The acute phase can last 12-18 months before onset of the chronic phase.2 Interestingly, pain usually resolves in 12-18 months in 90% of men.3  

PD affects approximately 3-9% of men worldwide and can be associated with pain, erectile dysfunction (ED), and penile deformity like shortening or curvature. PD can impact quality of life, self-esteem, psychological wellbeing, and sexual function. About 48% of men with PD experience depression and 81% experience emotional distress.3  

Further research is needed to better understand the risk factors, formation, and treatment of PD. Most common age range for onset is 55-60 years of age and is associated with erectile dysfunction, diabetes, obesity, hypertension, A-positive blood group, hyperlipidemia, smoking, and post pelvic surgery.2 PD typically occurs from multiple factors including penile wound healing in those who experience localized inflammatory response to microtrauma that results in fibrous inelastic (not stretchy) plaques creating a stiffening and curvature of the penis.3  

The most recent American Urological Association guideline was published in 2015, which is quite a few years ago at this point! Firstly, an intracavernosal injection (ICI) test with or without Doppler ultrasound should be performed prior to any invasive intervention. This test allows for the visualization of the penile deformity, plaques, and pain in the erect state. In some cases, a measurement of the angle of curvature in the erect state may be adequate. The intervention with the most research support from a medical standpoint is an intralesional collagenase clostridium histolyticum (CCH) injection. Intralesional means it is directly injected into the area of concern. This should be performed in combination with modeling (gentle stretching) to reduce the curvature particularly in those with curvature between 30 and 90 degrees.4 CCH basically assists the collagen fibers to lay in a more organized fashion instead of in a disorganized fashion with the plaques.3  

Penile traction and penile vacuums are other treatment options. Traction therapy is used to stop the continuation of scarring, recover penile length and girth, reduce curvature and enhance sexual function. Typically, this is used to either avoid surgery or simplify the intensity of surgery. A recent study looked at penile traction in the acute phase of PD and found that 40% of patients no longer required surgery. Traction therapy should be used no shorter than 6 months and must be worn for at least 6 hours per day.3 Vacuum therapy may be used for 10 minutes twice daily for 12 weeks. They are recommended with low-level evidence to reduce penile curvature and increase length. The low-level evidence is due to the limited number of studies performed thus far on these treatments.1  

Surgery is an option to aid in correcting the deformity and resuming sexual function; however, over 65% of patients experience dissatisfaction with surgical intervention for various reasons including loss of length, residual deformity or ED.3 Most providers will take a “wait and see” approach to determine how much resolution can occur with less invasive treatments in an attempt to either abstain from surgery or make the surgery less intensive with the hopes of improved outcomes.  

Because the American Urological Guidelines were published in 2015, it does not consider newer treatment approaches. For example, therapeutic ultrasound uses sound waves to promote tissue repair by increasing blood flow, reducing pain, and encouraging a proinflammatory response through heat. A randomized controlled trial split 43 men with PD into two groups. One group received 12 sessions of ultrasound over 4 weeks in 10-minute increments per session (2-3 sessions per week) and the other did not receive ultrasound during the 4 weeks. The group who received ultrasound showed a reduction in penile curvature of 17 degrees and a reduction in plaque size that averaged 0.37 mm. This is promising as therapeutic ultrasound is non-invasive.2  

So, how does pelvic floor physical therapy play a role in addressing Peyronie’s disease? Pelvic floor physical therapists (PFPTs) are trained to look at the relationship between the muscles, connective tissue, nerves, and blood flow to the pelvis and surrounding areas. If there is pain or restriction in one area, such as hardening of the connective tissue at the penis, there are techniques that can be used to reduce pain and improve mobility. A pelvic floor physical therapist can show you how to perform self-stretching or massage at home, specifically at the penile tissues, to complement your medical treatment. Additionally, PFPTs can use ultrasound in their sessions to assist with increasing blood flow and reducing plaque size in addition to manual techniques to further improve tissue mobility. When we are experiencing pain or restriction, we may also start to hold tension in other areas of our body, such as the pelvic floor and abdominal wall. A PFPT can provide instruction and home programs to ensure that a pattern of holding and tension does not continue to progress to other areas of the body. In short, pain management techniques are vital to increase comfort, reduce muscle tension, and improve blood flow to the area which is what skilled PFPTs can add to the plan of care for Peyronie’s disease. If you have been receiving medical treatment for Peyronie’s disease but feel that there is a missing piece to your care, reach out to a local pelvic floor physical therapist for an assessment!  

Written by Jordan Schmidt, PT, DPT  

Edited by Molly Hart PT, DPT 

References 

1. Teloken, P., & Katz, D. (2019). Medical Management of Peyronie's Disease: Review of the Clinical Evidence. Medical sciences (Basel, Switzerland), 7(9), 96. https://doi.org/10.3390/medsci7090096 

1. Milios, J. E., Ackland, T., & Green, D. J. (2020). Peyronie’s disease and the role of therapeutic ultrasound: A randomized controlled trial. Journal of Rehabilitation Therapy, 2(2). https://www.rehabiljournal.com/articles/peyronies-disease-and-the-role-of-therapeutic-ultrasound-a-randomized-controlled-trial.pdf 

1. Randhawa, K., & Shukla, C. J. (2019). Non-invasive treatment in the management of Peyronie's disease. Therapeutic advances in urology, 11, 1756287218823671. https://doi.org/10.1177/1756287218823671 

1. Nehra, A., et al. (2015). Peyronie’s Disease: AUA Guidelines. American Urological Association. https://www.auanet.org/guidelines-and-quality/guidelines/peyronies-disease-guideline 
2. Teloken, P., & Katz, D. (2019). Medical Management of Peyronie's Disease: Review of the Clinical Evidence. Medical sciences (Basel, Switzerland), 7(9), 96. https://doi.org/10.3390/medsci7090096