Peyronie’s disease (PD) is a disease characterized by calcification of the structure called tunica albuginea, which surrounds the cavernous bodies responsible for erection in the penis. The disease is common in men aged 40 and over. Treatment of Peyronie’s disease varies depending on the stage of the disease. Drug treatments are tried in the acute phase, that is, in the early stages. If there is no improvement after the acute period, surgical treatment is performed. There are different methods in the surgical treatment of PH. One of these treatments is penile prosthesis implantation (penile prosthesis installation, prosthesis surgery). In this article, I will talk about penile prosthesis application in the treatment of Peyronie’s disease, benefiting from my own experiences.

What is Peyronie’s disease?

Peyronie’s disease was first diagnosed by King Louis XV of France in 1743. It is called by this name because it was described by Francois Gigot de La Peyronie, the doctor of Louis XIV. The disease manifests itself with plaque formation in the tunica albuginea. It is seen at all ages, and is most common in people aged 50-60. Clinically, the most important complaint (symptom) is that the penis bends towards the side of the curvature during erection. Pain that occurs in the early phase of the disease disappears in the stable period. The exact cause is unknown, there is no risk of turning into cancer.

What are the treatment methods for Peyronie’s disease?

Treatment of PH varies depending on the stage of the disease. The acute phase lasts 2-4 weeks and sometimes up to 1 year. In the chronic phase, disease symptoms have become stable. There is no pain during this period. Pain, penile deformity and penis shortening remain constant in the chronic phase.

In the acute stage (early stage), treatments such as injection treatments into the penis, painkillers, and ESWT (shock wave therapy to the penis) are applied. There are different treatment options in the chronic phase. Permanent treatment is surgical treatment in these patients. Different surgical methods are applied. It is the most commonly performed penile plication and graft method. If the patient also complains of erectile dysfunction, the most appropriate option is penile prosthesis implantation. We have been successfully applying treatments appropriate to our patients’ conditions for a long time.

If there is PH, when is surgery required?

Surgical treatment is performed after the acute phase of PH has passed. Not every patient requires surgery. Surgical treatment should be considered in patients with PH in the following cases:

• If there is severe penile curvature: If it prevents intercourse or if the partner experiences pain during intercourse, surgery is required. Additionally, if there is a curvature of the penis that disturbs the patient psychologically, surgery is also required.
• If there is erectile dysfunction: If there is ED along with PD disease and there is no response to treatment, then patients should undergo penile prosthesis surgery.

What are the surgical methods for Peyronie’s disease?

After the acute phase of PH treatment passes and the patient enters the stable phase, the patient is evaluated and appropriate treatment is given. The surgical methods frequently used in the surgical treatment of this disease are as follows:

• Penile plication surgery
• Graft method
• Penile prosthesis surgery

Is erectile dysfunction seen in Peyronie’s disease?

On average, 22-55% of men with PD disease have varying degrees of erection problems (erectile dysfunction). There are different reasons for this. We can list the causes of erectile dysfunction in Peyronie’s disease as follows:

• Age of patients: It is higher in older ages
• Other coexisting causes: If there are diseases such as diabetes, obesity, hypertension, hypercholesterolemia; ED is more common in these people if they use alcohol, smoke and have a sedentary life.
• Psychological reasons and stress factor
• Penile pain caused by the disease
• Severe penile deviation (penis curvature) and the anxiety it causes

What treatment methods are used in patients with PD if they have ED problems?

Not every person with HP necessarily experiences erectile dysfunction (ED). If people with PD also have ED problems, this problem also needs to be treated. ED treatment in patients with PD is generally similar to ED treatment. We can list the ED treatment principles in Peyronie patients as follows:

• Lifestyle changes
• Treatments should be made for underlying causes such as diabetes mellitus, DM and hypercholesterolemia.
• PDE5i group drugs
• ESWT treatment
• Penile injection therapy
• Application of penile vacuum

In what cases/to whom is penile prosthesis implantation performed in Peyronie’s disease?

Penile prosthesis is not placed on patients with the disease. Appropriate treatment should be selected according to the stage of Peyronie’s disease and the patient’s condition. The most important thing to consider when installing a penile prosthesis in the treatment of Peyronie’s disease is erection status. If the erection problem is mild to moderate and will benefit from methods such as medication or ESWT treatment, these methods are tried. If the patient has serious erection problems and no positive results are obtained from existing treatments, there is no need to use other surgical techniques in these patients. In this case, the most appropriate and correct treatment is penile prosthesis implantation, that is, the installation of a penile prosthesis.

To put it briefly, the treatment of choice for Peyronie’s patients with erectile dysfunction (erectile dysfunction) is a penile prosthesis. Prosthesis surgery is the last option in the stable phase of the disease and when other available treatments fail to yield results.

If there is a curvature in the penis due to Peyronie’s disease, can it be corrected with a prosthesis?

One of the problems in people with PD is penis curvature. Penile curvature is also known as penile curvature or penile deviation. The degree of curvature may vary depending on the location and size of the plaque. Penile curvature can be on the right or left side, up or down. If the curvature is severe and prevents patients from having sexual intercourse, this condition must be corrected surgically. There are two main methods in surgical treatment: Plication method and graft method. The disadvantage of the plication method is that it causes shortening of the penis. Appropriate treatment is given according to the patient’s condition. We perform both methods on our patients.

In patients with curvature of the penis due to Peyronie’s disease, it is possible to correct the curvature with a prosthesis. The degree of curvature is very important here. In those with mild curvatures, it is easier to correct the curvature with a prosthesis. If there is a serious penile curvature, there are some methods to correct it with a penile prosthesis. The methods used to correct the curvature with penile prosthesis in Peyronie’s patients are as follows:

• Manual correction
• Incision method
• Plication method
• Patch (grafting) method

Which type of penile prosthesis is used in Peyronie’s disease?

There are two main types of penis prostheses: Malleable, or bendable, penis prostheses and inflatable prostheses. Malleable prostheses are prostheses that are permanently erect. These are made of special materials that can be bent. Patients can have intercourse whenever they want. Inflatable dentures or three-piece dentures normally remain deflated. When patients want to have intercourse, they create an erection and have intercourse.

Malleable, that is, one-piece dentures, are easy to use and have no risk of malfunction. They are cheaper prostheses. Since it is in constant erection, there is a risk of erection in the head of the penis. Three-piece prostheses are optionally inflated; they do not remain in a permanent state of erection. These types of prostheses are more useful and similar to normal erection. Three-piece dentures are somewhat complicated structures. For this reason, it is difficult for the very elderly and those with problems with their hands and fingers to use it. It is expensive compared to one-piece dentures. We prefer three-piece prostheses to patients who are economically and socioculturally suitable.

Both types of penile prostheses can be used in patients with Peyronie’s disease. When we examined the literature, it was reported that positive results were obtained with both prostheses. We prefer both prostheses to our suitable patients. Patient satisfaction is high with both prosthesis types. If our patients are young, have no physical obstacle to using the prosthesis, or have no financial difficulties, we prefer three-piece prostheses.

What is patient satisfaction like after PH and penile prosthesis?

Patient and partner satisfaction is quite high in patients who underwent penile prosthesis surgery due to erection problems. On average, the satisfaction rate of patients and their partners who have a penile prosthesis is 95-98%. Patient and partner satisfaction after penile prosthesis surgery in patients with PD has been reported to be 75-80%. We observed similar rates of satisfaction in our patients.

Literature information about PH and penile prosthesis surgery

There are many clinical studies in the literature regarding penile prosthesis application in PD patients. When we evaluate these studies in general, the following results stand out:

• If Peyronie’s patients have erectile dysfunction and do not respond to existing treatments, penile prosthesis installation should be considered as the last option.
• Penile prosthesis surgery should be performed in the stable phase of the disease.
• It is possible to correct penile curvature with penile prosthesis. Some methods are used for this, especially in patients with severe curvatures.
• Patient and partner satisfaction is high.

What are the complications that may occur as a result of penile prosthesis surgery for people with PD?

Penile prosthesis surgery is a successful surgery with very few complications when performed by experienced hands. Some of these are problems that may occur in all penis prosthesis surgeries. Although rare, we have observed complications that may occur after prosthesis surgery in PD patients. The following are the complications.

• Shortening of penis length
• Prosthetic infection
• Mechanical malfunctions in three-piece prostheses
• Penile curvature continues to varying degrees
• Erosion in the penis due to prosthesis
• Problems with the use of the prosthesis
• Loss of sensation in the penis

In summary: If there is an erection problem along with Peyronie’s disease and there is no positive result from existing treatments, then penile prosthesis implantation is the last option. The stable period of the disease should be preferred for surgery. Both one-piece and inflatable types of penile prostheses can be fitted to these patients. If the patient is suitable, inflatable prostheses should be preferred. We prefer the three-piece penile prosthesis to our suitable patients. The satisfaction rate of patients and their spouses who receive prosthesis is quite high. Surgery-related complications are extremely low.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY