Apr 27, 2021

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Dr. Smith: Yeah, I got rid of all of our dogs, and we just have six kids now. So it's a little different.

Scot: Traded in dogs for kids.

Dr. Smith: It's the same amount of urine on the floor, though.

Scot: Welcome to "Who Cares About Men's Health." Today's show is part of our Men's Health Essentials series. These are conditions that impact men. Today, we're talking about something called Peyronie's disease.

First, the introductions. My name is Scot. I'm the manager of thescoperadio.com, and I care about men's health.

Troy: And I'm Dr. Troy Madsen. I'm an emergency physician at the University of Utah, and I care about men's health.

Dr. Smith: And I'm Dr. John Smith. I am a urologist at the University of Utah, and I definitely care about men's health.

Scot: Peyronie's disease, from what I understand it's a condition where scar tissue can cause the penis to curve or lose length or girth. It's painful, and it can impact a man's physical and emotional health. And from what I understand, a lot of men suffer in silence about it. They don't think that there are any treatments, or they don't want to talk about it, but there are treatments.

Troy: And help me understand a little bit more what this is. Is this something that people are born with? Is this something that develops over time? What exactly are we talking about here?

Dr. Smith: So one of the things is some men have a natural curvature to their penis and it's not necessarily a problem. Whenever I'm talking with patients who have Peyronie's disease, our goal is to get them functionally straight. What that means is they're never going to be straight as one of Robin Hood's arrows that he's going to shoot out of his bow, but they'll definitely be able to perform sexually and comfortably. That's one of the reasons that a lot of men will come in, is they have difficulty being able to have sexual intercourse in a way that's not uncomfortable for them or their partner.

Scot: What kind of curve are we talking? Because I would imagine, all guys can be a little different. One guy is going to point off to one way, and the other the other way, but what is a Peyronie's curve?

Dr. Smith: So Peyronie's disease, the definition is a curvature of the penis that occurs and makes it difficult for someone to have normal sexual function or even urinary function. So if you're curved, it can range anywhere from a few degrees all the way up to 90 degrees. I've got a picture here in one of the textbooks when I was just going over some of this stuff you might be able to see here, but it's literally bent almost 170 degrees. And so that's a very aggressive curve.

Scot: That's curving up. Am I seeing that right? That's curving up?

Dr. Smith: Yeah, it's curving back on itself.

Scot: Is that common? Is it up, or is it to the side, or is it all directions it can bend?

Dr. Smith: It's all directions. It just depends. And sometimes it's multi-directional. Sometimes it can be up and to the left, down and to the right. It really just depends on the patient. So those are the things that . . . we deal with each case individually to come to a conclusion on what the best treatment is.

Troy: And does that kind of thing happen from an injury, or is this a penile fracture that wasn't treated, or is it just something that develops with some fibrous tissue over time or a combination?

Dr. Smith: So it's usually fibrous tissue that happens over time. If you have a penile fracture, those are generally very detrimental to the erectile function. Most of the time, these Peyronie's curves start off and they just worsen over time. You get patients who will say, "Well, over the last six or eight months, I've noticed a big increase in this curvature."

And Peyronie's disease, we don't really know what causes it. The theory behind it is that there's some micro-trauma there that then causes a scarring between the two corpora cavernosa. Anatomically, there are three chambers to the penis, two on the top and one on the bottom. The two on the top are called the corpora cavernosa. The one on the bottom is called the corpus spongiosum. And it also incorporates the urethra.

So in between those two chambers on the top, the corpora cavernosa, there can be some scarring. And if there's scarring on one side or the other, that will pull the penis to that side and cause curvature and shortening of the penis.

Scot: And just to be clear, when you're flaccid, you don't notice this, right? It's only erect penises that you get that curve. You're shaking your head no.

Dr. Smith: Correct. So you can feel the Peyronie's plaque in a flaccid penis. That doesn't necessarily mean that it's curved, but you sometimes can feel a very distinct area on the penis where that plaque and that curvature begins. And so you can get an idea when they're flaccid, but you won't see the curvature until the penis is erect.

Troy: So this raises an interesting question. If you're diagnosing this in a clinic, do you have to require that a man is erect to be able to determine what's going on, and how does this affect a guy's willingness to come into a clinic?

Dr. Smith: Right. So a lot of gentlemen who come in, they're ready to talk about this because they've been unable to function sexually or they've been peeing into the wall or something like that, where their curvature is bad enough where they want to do something about it.

Most men who come in . . . I guess I shouldn't say most. But some of them will have taken photographs that they'll bring in to show.

But as part of the workup, we offer them what's called a penile duplex ultrasound where we bring the patient into the clinic and we do a special ultrasound where we inject the penis with a special medication called TriMix. It helps to give an artificial erection to the patient.

We measure the penis. Once it's erect, we measure the curvature with a goniometer, the same thing you would measure angles with when you were doing trigonometry in school. We measure the curvature of the penis so that we know exactly what the curvature is, and we also measure what directions the curvature is in, whether it's up, down, left, right.

Scot: Before we get to the treatments, is this something that just gradually starts showing up? You just gradually start noticing and it gets worse and worse? Does it come on pretty quickly? And then the follow-up to that, the sooner you treat it, the better?

Dr. Smith: So I think you could say yes to all the above. So sometimes it comes on quick. Sometimes it's longer lasting. Oftentimes, men will report that there was a little bit of pain and irritation of the penis, and they noted the curvature worsening. And there is a maturation of that area of the scar over the course of three to six months where that pain dissipates, goes away. And that's where the curvature settles into what it's going to be long term without any treatment. For some folks, that lasts a little shorter. For some folks, that lasts a little longer.

And then, again, the sooner that you come in . . . if you come in during that acute phase, where there's still change happening to the curvature, oftentimes we won't recommend treatment for that because we don't know where the curvature is going to finally end up and we'd like to let that plaque mature. There is some debate on that nowadays. Some people are treating these earlier. But as a rule, generally, we'll let that mature so that we know what kind of curvature that we're trying to correct.

Troy: And it's interesting, though, that you say this just all happens. It all of a sudden really gets worse over six months. Is there a certain age where it seems to happen?

Dr. Smith: So it usually happens in older men, but it can happen at any time. We have men who come into the clinic in their 30s, 40s, 50s, 60s, all the way on up. I would say a majority of folks that come in are over the age of 45, but it can happen at any age.

Again, we don't really have a good reason for it a lot of times. Sometimes people can pinpoint it to maybe a sexual encounter where they noticed that there was a bend to the erection that then afterwards they noted some curvature, or they had an injury some other way that they started to notice pain and curvature of the penis afterwards. But most of the time, it's just an insidious onset where they can't really pinpoint anything where they had an issue.

Scot: I've got a couple of things I found on Reddit here I just want to throw out quickly before we get to the cure. So there were a couple of things that said it can be an injury during sex. And I even found this on a couple of what I would consider legit medical sites. You said we're not too sure if that's what's causing it or not. What's your take on that?

Dr. Smith: So that is the theory, that there is some micro-trauma happening at some point. And the time when the penis would be under the most stress would be during sexual intercourse. So that's oftentimes the theory that's put behind it. However, no one really knows for sure.

Like I said, some patients come in and they can pinpoint a sexual encounter where they did notice a bending of the penis that was painful and then the curvature started after that. But however the micro-trauma happens, it definitely can be. And so a lot of times we do look for a time when the patient may have had a sexual encounter where there may have been a bending or an abnormal bending of the penis that may have caused some of this damage.

Scot: On Reddit, I also saw that some people thought medications cause it. A lot of people would say, "Yeah, I was on such and such medication, and that's when it happened." Is there any truth to that?

Dr. Smith: So, again, I think that there can be some truth to that. There's not really good evidence to guarantee any of that. But again, you can't say yes or no 100% about anything. There are some medications that can cause fibrosis and things like that that people have pointed to. "Well, I didn't have any of these issues before I took these medications." So that definitely could be the case.

Troy: I guess with all this in mind then, what's someone going to do about this? Obviously, the answer, it sounds like, is come talk to you. And then if I come there, and there's clearly an issue, what should I expect next?

Dr. Smith: So you come in and you see us. We're going to recommend doing the ultrasound to measure the curvature because looking at how much curvature you have can really make a difference.

Some men just want some reassurance. They're functionally straight, they're not having difficulty with urination or sexual function, and they just want reassurance that it's not something that's going to be a huge deal. And if that's the case, then maybe we do nothing for those folks.

But again, looking at it, if it is something where it is problematic, there are treatment options. We'll talk about it from least invasive to most invasive. So there are no real good oral therapies. I know some people will say, "Oh, you can take this oral therapy to straighten things out." None of those have been shown to be effective.

Scot: Name a couple of those because I did actually look . . .

Troy: Yeah, you piqued my interest. I'm curious. Are we talking ginseng or . . .

Dr. Smith: You'll see things like coenzyme Q10, vitamin E, POTABA, colchicine, different things. Some people say Omega-3 fatty acids. People will say, "Well, if you just take Viagra, it'll help you straighten out." None of those things have been shown to really do anything to help with the curvature of the penis.

The three things that we generally offer folks in the office . . . the ultrasound to evaluate their curvature properly. Generally, the photos that they bring will let us know that they do have curvature, but they're not really accurate as far as getting measurements. So we want to know how much curvature they have because that can really dictate treatment options.

And there are three treatment options that we generally offer our patients. One is a penile straightening device. These devices are worn on the penis for a duration of time to help straighten out that curvature. They're generally worn for a few to several months at a time. Some of them range between two sessions of 30 minutes a day all the way up to nine hours a day and monitor the curvature to see improvement.

Scot: So that's something you can wear under your clothes if it's nine hours a day. Or is it at night?

Dr. Smith: Not usually. It's pretty bulky. They're not really able to be worn . . . they don't want you to sleep with them. So it's very prohibitive for a lot of people. I think with COVID where people are staying home a little bit more, it may have been a little bit easier of an option for some folks. But again, you're not going to put that on and go to the office with it.

Troy: That sounds like it would work for a Zoom meeting.

Dr. Smith: Right. It would. Yep, you could have your button-up shirt on the top and your basketball shorts on the bottom.

Scot: All right. So that's Option 1. What are the other two options that you offer? And how many people take that option, by the way?

Dr. Smith: It depends on the patient. A lot of people actually say, "Well, I'd rather try that than do the other two options." And you may understand that once I talk about the other two options.

Scot: It's not going to get better, huh?

Troy: What's next?

Dr. Smith: Well, this is the least invasive option. This doesn't require any other needles or any other surgical intervention on the penis other than the ultrasound where we do inject the medicine during the ultrasound.

And so the second option that we offer is an injection that goes directly into that scarred area of the penis. We call it the Peyronie's plaque. And that Peyronie's plaque is injected with the collagenases material. And this is done by injecting that site with a series of injections, and then allowing the patient to go home and do what they call modeling of the penis for a duration afterward before repeating a series of injections. No sexual intercourse for four weeks after that injection series because you don't want to risk any rupture of the penis causing a penile fracture.

And so that's Option 2 that we offer, and that can be done in multiple cycles. Three or four cycles can be done to improve the curvature of the penis.

The caveat to that one is you have to have at least a 30-degree curvature of the penis before that's even an option. That's what the research was done on it, that you have to have at least 30 degrees of curvature for that to be an option for treatment.

So number three is a surgical intervention. It's called a penile plication. They go in, they induce an artificial erection in the penis while you're undergoing surgery, and they place sutures to straighten the penis out. This is obviously the most invasive, and at the end of the surgical procedure, they try to get it as straight as they can and then allow for healing.

This does cause some shortening of the penis because sutures are generally placed opposite of where the scarring is, which causes that shortening of the penis that you had to be permanent. You do lose some length with that. So a lot of patients are a little skeptical when they hear that. But this is the quickest route to get you back to straight because it's a surgical intervention. It's a one-and-done.

Reviews are mixed if you ask different urologists what they think. Some of them are very . . . they like plication. Some of them think that it's not the greatest option and they would avoid it if they could. But it is an option and sometimes it is the option that's best for some men.

Troy: So what would you choose if you were doing this?

Dr. Smith: It depends on what my curvature looked like. I think if I had a moderate curvature, I would likely try a penile traction device because it is the least invasive. I would probably try that first if my curvature wasn't severe.

Scot: Any last thoughts or concerns that men have when they talk to you about this sort of issue that you'd like to get out there in the world?

Dr. Smith: I think a lot of times just having conversations with folks to just know that there is something that you can do. If it is something that's bothering you, at least having that conversation to have an understanding.

I think there are some misconceptions out there. I've had men come in and think that they had penile cancer when really they just had a very mild curvature of their penis, and to give them reassurance is helpful.

But if you know that this isn't something that's going to hurt you, it's not going to shorten your lifespan, it's something that is treatable . . . I think a lot of men just want that hope of being able to function appropriately again. And I think that would be my lasting thing. There is something we can do.

Scot: Thanks for joining us for our Men's Health Essentials series on Peyronie's disease.

Hey, check out some of our other episodes too where we talk about diet and nutrition and exercise and sleep and managing your stress, those things that we need to do to stay healthy now and be healthy in the future. We give you some tips and talk to some experts about that sort of thing.

If you have any questions, you can reach out to us at hello@thescoperadio.com, you can call us on our listener line 601-55SCOPE, or you can go to facebook.com/whocaresmenshealth. That's where you'll find the community of men that were trying to build that do care about their health.

Thinking about health in a different way, this is "Who Cares About Men's Health." Thanks for listening. Catch you next time.


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