What Can I Do About My Bent Penis -- Peyronie's Disease
And other possible dysfunction questions.
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Dear Karl,
I have a problem that is a bit embarrassing to ask about -- it is, technically, called Peyronie's disease.
Do you know of any natural remedies to this situation?
XX
Below I have a standard explanation of Peyronie's disease -- where scar tissue builds up on the penis and prevents it from be straight when you have an erection.
A US Patent has been issued showing that Alpha Lipoic Acid reduces scar tissue -- it would be easy and safe to try as an external application. MSM would be much cheaper to try. If it doesn't work, try alpha Lipoic Acid.
Let me know what else you think about this. If you try this remedy I certainly want to hear of your results.
Cordially,
Karl Loren
Source
PEYRONIE'S DISEASE: CURVATURE OF THE PENIS
Peyronie's disease is a severe curvature of the erect penis. It's named after an Italian physician to King Louis XIV of France. This physician was the first to note the disorder back in the 1700s. While it is somewhat common, it is not often mentioned.
A minor bend in the erect penis is perfectly normal, as few penises are straight as an arrow. In some cases of Peyronie's, however, the penis can form a "J" or a corkscrew, making intercourse impossible.What causes a curved penis?
The cause of Peyronie's disease is unknown. Some physicians theorize the cause of the curvature may be from trauma to the penis, perhaps if the penis is bent backward during rough sex. The injury causes an inflammation in the tunica, and subsequently leads to scarring.
There are other theories, and some reports suggest that men who take beta-blocking medications for high blood pressure develop Peyronie's.
How is the penis constructed?
The penis is composed of three cylindrical cavities. The two on top are called the corpus cavernosa, and the one on bottom the corpus spongiosum, which contains the urethra (the tube that urine flows through).
The two top corporal cavities expand to trap and hold the blood that produces an erection in the male. The bottom body, corpus spongiosum, functions mainly for the passage of urine. Each of these corporal bodies is surrounded by a very elastic covering called the tunica albuginea.
On top of the two corporal cavernosa are the superficial nerves and blood vessels of the penis.Why does the penis curve?
In Peyronie's disease, the normal elastic tissue of the tunica is replaced by scar tissue. Normally with erection the elastic tissue of the penis expands and elongates symmetrically resulting in a straight erection. Because the plaque, or scar tissue, is not elastic, but rather hard, it will not stretch with erection.
The disease starts as a small bump or constriction on the shaft of the penis below the skin, which expands to form a flat deposit that's sometimes as large as the diameter of a silver dollar. This "plaque" invades and replaces the elastic covering of the penis with inflexible material. When a man with Peyronie's has an erection, the plaque does not expand, so the penis curves to one side.How does a curved penis affect sexual intercourse?
A third of men with Peyronie's have pain with their erections. A few men with Peyronie's become impotent. In some cases, the head of the penis does not fill with blood.
Because inflammation is initially associated with the scar tissue, there can be some discomfort with erection and distension. Many patients complain not only about the curvature of the erection but the loss of length and girth. These are all results of the inelastic tissue and lack of distention that results.
Most patients with Peyronie's disease can continue to function sexually with the curvature in the penis. Rarely, some patients with greater distortion are unable to have satisfactory sexual intercourse.Does a curved penis cause impotence?
Recent studies indicate that some men with Peyronie's disease lose the ability to trap the blood in the penis. It can, however, be difficult to distinguish the man who has a leakage problem from one who is quite anxious about his penis and loses his erection secondary to anxiety and stress.
Most of the time the plaque is on the top surface of the penis causing an upward bend. However, plaques can occur at any point on the penis. In some patients the penis beyond the plaque will not become as rigid.How common is a curved penis?
Peyronie's disease is an extremely common ailment. At the Male Health Center, physicians see about five patients a week with this problem.
Most patients are middle-aged, though the youngest patients we have seen are in their twenties, and there are a number of still sexually active men in their eighties with the disease.
Some men first notice the sudden onset of a curved erection even though the previous erection was straight. In other men, the curvature may be slight at first, but then it keeps getting worse. Eventually, the curve stops, and gets no worse. In most cases, the active process of Peyronie's disease lasts less than a year. At the time the process stops, the scar tissue may remain or in some cases disappear.How can you straighten a curved penis?
Rather than focus on cosmetic goals related to the aesthetic ideal of an arrow-straight penis, the real goal of treating a curved penis is to keep or restore sexual function.
Physicians are aware that a man can have a great deal of apprehension and anxiety associated with a curved penis. There is absolutely no connection between Peyronie's disease and cancer, for example.
There is no specific therapy for Peyronie's disease. We presently prescribe 400 units of vitamin E to be taken with meals. It is theorized that vitamin E promotes healing and prevents scarring. Additionally, we prescribe Advil for its antiinflammatory effects, to be taken with meals. For men having significant pain with erections, a drug called Colchicine may be used. Before beginning this treatment, patients should have their white blood cell count checked to ensure that there is no change with this medication.
At the Male Health Center we are currently conducting a study from the University of Chicago that uses injections into the scar tissue.
No other non-surgical treatment for Peyronie's exists. And steer clear of any physician recommending bizarre treatments, including steroid injections into the plaques (which don't help). Radiation and ultrasound are of no benefit. Oral potaba, which is often prescribed in huge quantities, is of no benefit.
When the disease process stops, there is usually some residual distortion of the penis but the vast majority of patients are able to function adequately sexually. However, if there is enough distortion of the penis to preclude sexual intercourse, surgery is possible.Can surgery straighten a curved penis?
Surgical alternatives include tightening or tucking the penis opposite the curvature to produce straightening. This usually results in some small loss of length.
The Nesbitt Tuck is a 10 to 20 minute outpatient procedure that puts a stitch at the underside of the maximum point of the curve. It requires about a week off work and discomfort with erections for four to six weeks. Another surgical treatment consists of incision to the plaque or scar tissue and patching with a vein. Since this is usually on the top surface of the penis, the nerves and blood vessels previously described must be elevated.
A specialized surgeon may be able to cut away the plaque and graft new tissue, treat the side opposite the plaque, or install a penile implant. The first two approaches may cause impotence, since they may damage the tissue within the penis. The penile implant is the last resort.
Some new treatments involve the use of lasers to remove the plaque, which may pose less risk of tissue damage. But this technique is still experimental and not widely available.What does the Male Health Center recommend?
Generally speaking, we at the Male Health Center recommend that the man be patient enough to see if the problem will correct itself, because one-third of cases get better within 18 months after the onset of the problem.
During this period, we recommend 400 international units of vitamin E three times a day. While the application of vitamin E at this time is not substantiated in scientific journals, the vitamin E won't hurt you and may, in fact, help prevent heart disease.
If a mild curve does not get better within 18 months, further treatment may not be recommended, as long as the bend itself isn't severe enough to prevent intercourse, and the problem doesn't pose the risk of impotence.
In the case of an extreme curve, painful intercourse, or if there is the potential for impotence, surgical correction of the curve may be necessary.
Generally speaking, if the bend is not severe, and it doesn't prevent sex, we at the Male Heatlh Center recommend trying to live with it. Considering that few partners will see your penis on display, a curved penis that doesn't affect your sex life is something you and your partner can learn to appreciate as just another unique aspect of you.
Peyronie's Disease: Current Management
- JAMES FITKIN, M.D., and GEORGE T. HO, M.D.
- Mount Carmel Health System
- Columbus, Ohio
A patient information handout on Peyronie's disease, written by the authors of this article, is provided on page 554.
Peyronie's disease is an acquired inflammatory condition of the penis associated with penile curvature and, in some cases, pain. It primarily affects men between 45 and 60 years of age, although an age range of 18 to 80 years has been reported. If left untreated, Peyronie's disease may cause fibrotic, nonexpansile thickening of relatively discrete areas of the corpora tunica, typically resulting in focal bend, pain or other functional or structural abnormalities of the erect penis. Many cases resolve without treatment. Medical therapies, including antioxidants (such as vitamin E and potassium aminobenzoate) and corticosteroids injected directly into the plaque, lack adequate scientific support. Surgery remains a mainstay when conservative measures fail. (Am Fam Physician 1999;60:549-54.)
Peyronie's disease was first described in 1704. It is named for Francois de la Peyronie, who, in 1743, described a patient who had "rosary beads of scar tissue to cause an upward curvature of the penis during erection." The penile curvature of Peyronie's disease is caused by an inelastic scar, or plaque, that shortens the involved aspect of the tunica albuginea of the corpora cavernosa during erection.1,2 In approximately one third of patients, the scarring involves the dorsal and ventral aspects of the shaft. Such offsetting plaques may cause the penis to be straight but shortened or to have a lateral bend (Figure 1). The circumference of the shaft may also be reduced, resulting in an erect penis that is flail at the site of the constriction, firm proximal to the constriction and soft distally.3
The first symptom of Peyronie's disease may be focal pain with erection, new curvature with erection or inability to penetrate as a result of curvature or distal flaccidity.3,4 Some patients who do not have pain with erection have tenderness on palpation of the indurated plaque.
FIGURE 1. Penile curvature associated with Peyronie's disease. (A) anatomy of a normal erection. (B) Peyronie's disease. Penile cross-section showing plaque between the corpora. (C) Penile curvature. Fibrous plaque prevents uniform lengthening as erection occurs. As the rest of the corpus cavernosum and corpus spongiosum lengthen, the penis bends toward the involved area.Potential Etiologies
A number of authors believe that Peyronie's disease results, in part, from trauma.5-7 More than 75 percent of patients with Peyronie's disease are between 45 and 65 years of age, when elasticity of the collagen of the penis has diminished.5 Many patients recall an episode of penile trauma, such as an invasive procedure, blunt trauma or injury during intercourse, at the site of subsequent plaque formation. Up to 47 percent of patients with Peyronie's disease also had another condition associated with loss of elasticity, such as Dupuytren's contracture or Ledderhose's disease (fibrosis of the palmar and plantar fascias, respectively).8-11 Some authors5,12 suggest that either a single episode or recurrent episodes of flexion of the tunica albuginea may result in tears that bleed and form a clot, with subsequent fibrin deposition. Biopsy may demonstrate fibrin deposition and perivascular inflammation underlying the tunica albuginea and, occasionally, within and beneath Buck's fascia overlying the plaque.5
Presentation
Patients typically present with focal pain that occurs with erection, bent erection, presence of a hard mass and/or inability to have intercourse secondary to flail penis distal to the lesion.3 One half to two thirds of patients with Peyronie's disease describe pain as a symptom. Pain is associated with the inflammation generated by the active phase of the healing process, and it typically disappears as the inflammation resolves. It is believed to be the result of inflammation of the adjacent Buck's fascia, since the tunica albuginea itself has no nerve fibers.5
Clinical Course
During the first year or so after formation of the plaque, while the scar in the tunica is undergoing the process of remodeling, penile distortion may increase, remain static or, as is most often the case in younger men, resolve and disappear spontaneously.3-5 In most patients the curvature remains static as the scar matures although, in some patients, it becomes worse as fibrosis ensues and the scar contracts. In 25 percent of these patients the scarring process progresses to calcification, and in 25 percent of those it progresses to bone formation.3,5
Patients with Peyronie's disease may present with a painful, bent penis on erection, a palpable, hard penile mass and a flaccid penis distal to the lesion. After the scar has matured, the configuration of the tunica albuginea is unlikely to be changed by nonsurgical treatments.4 However, many patients with advanced disease who have not sought surgical correction have been able to continue mutually satisfactory sexual intercourse with a partner. Approximately one third of patients with end-stage disease have a disabling curvature that requires surgical correction.
Pain that occurs in conjunction with Peyronie's disease may also progress with the onset of new injuries to the corpora cavernosa occurring as a direct result of the patient's attempts to correct or compensate for the original defect during sexual intercourse.5 One of the more common reasons for seeking treatment involves discomfort of the patient's partner during intercourse, which is associated with penile curvature.
Diagnosis
Indurated plaques may be palpated on physical examination of the penis. Such palpation may elicit pain if the disease is still in the inflammatory stage. Corroboration of Peyronie's disease may be obtained by having the patient photograph the erect penis, demonstrating curvature, an hourglass shape or flail distal penis.
Radiographs of the penis may show calcification in 20 to 25 percent of patients with end-stage disease, and 25 percent of these patients have frank bone.3,5 Doppler flow studies and results of dynamic infusion cavernosometry and cavernosography are normal both proximal and distal to the plaque, demonstrating that disparity in the erection is not associated with lack of blood flow at or beyond the lesion.3-5
Treatment
Despite numerous treatment options, there is no generally accepted, standard nonsurgical treatment for Peyronie's disease. Moreover, the success of treatment may be difficult to assess because 20 to 50 percent of patients with Peyronie's disease experience spontaneous resolution.4 This potential for improvement probably warrants delay of surgical correction for at least six to 12 months after diagnosis unless the plaque is calcified or the patient is completely incapable of sexual activity.4
Oral agents, particularly those with antioxidant properties, have been tried with limited success. Such agents include vitamin E,10 potassium aminobenzoate (Potaba),13 and colchicine. Experimental intralesional treatments include corticosteroids, parathyroid hormone,11 collagenase and verapamil (Calan).8,14,15 Various modes of energy transfer, including ultrasound, radiation, laser therapy, short-wave diathermy and lithotripsy, have also been used.10,16,17 However, all current published reports of these treatments have been compromised by limited-sample patient populations, lack of control populations, poorly characterized outcome parameters, inadequate follow-up periods and inconclusive results. It has been difficult, therefore, to determine which, if any, of the nonsurgical treatments may be effective. Caution should be used when recommending any of these experimental treatments.
Vitamin E and Verapamil
One possible medical regimen is 100 mg of vitamin E taken three times a day for a minimum of four months. Theoretically, this antioxidant will prevent further development of plaque, although studies have suggested that it is no more effective than placebo.
The most commonly used surgical procedure for Peyronie's disease is excision of the plaque and a patch graft using the patient's skin. Injectable verapamil also has received some attention recently, although studies have either shown no statistical improvement over placebo or have been critically compromised by very small study size.14,15
Potassium Aminobenzoate
Potassium aminobenzoate is considered a member of the vitamin B complex and is believed to promote antifibrotic activity through its mediation of increased oxygen uptake at the tissue level. Potassium aminobenzoate is rapidly excreted in the urine, so dosages are given at approximately three-hour intervals.13The standard regimen of potassium aminobenzoate is 12 g daily, divided into six doses of four 500-mg tablets. The total of number of tablets per day is 24 (720 tablets per month). Since a minimum of six to 12 months of treatment is recommended, patients must take a huge number of pills during the course of treatment to achieve any benefit. In a study of 21 patients with Peyronie's disease who were treated with potassium aminobenzoate,13 morphologic deformity resolved completely in 18 percent of the study subjects and decreased in an additional 82 percent. The plaque resolved completely in 11 percent and decreased in size in an additional 67 percent, and pain resolved in every patient.13 A retrospective review18 noted that no well-controlled prospective, double-blind study containing adequate study subjects has been conducted to establish the efficacy of potassium aminobenzoate in the treatment of Peyronie's disease. Since the rate of spontaneous resolution is high, the results with potassium aminobenzoate may be no better than the results with placebo.
Corticosteroid Injection
The corticosteroid preparation used in the treatment of Peyronie's disease varies, but two common regimens are dexamethasone (Decadron), in a dosage of 0.2 to 0.4 mg per plaque injected weekly for 10 weeks,8 and triamcinolone hexacetonide (Aristospan Intralesional), in a dosage of 2 mg administered once every six weeks for a total of six injections. Courses of treatment have been repeated in some instances. A small syringe and a fine needle are used to inject the medication into the plaque and the tissues immediately adjacent to it. Local anesthetic agents are not used routinely because of the risk of injection into the vascular corpora.Using the dexamethasone regimen in 31 patients, one study13 reported an 81 percent benefit to a moderate or greater degree, with 42 percent of patients achieving what they described as marked improvement. In a study4 of 42 patients treated with triamcinolone, 33 percent of patients had complete recovery or marked improvement in symptoms and signs during the course of treatment.
Steroid injections are probably most effective during the initial formation of Peyronie's plaque, and success is limited with mature plaques. Patients are advised to abstain from sex during treatment to minimize further potential trauma to the penis.
Surgical Management
A number of surgical techniques are used for treatment of Peyronie's disease. The technique should be individually chosen for each patient. The optimal surgical approach considers penile rigidity, degree of curvature, shaft narrowing and erectile response.19 One commonly used surgical technique, the Nesbit procedure, involves excision of the plaque accompanied by "patch grafting" of the defect left by the excision. Graft material generally is taken from scrotal tunica vaginalis or nonhair-bearing skin from the forearm. Artificial graft material such as Gortex has also been used but with mixed results. These materials are generally less elastic and do not permit adequate stretch of the corpora during erections. Other techniques include penile prosthesis and plication of the tunica albuginea.Excision of the plaque has been associated with complaints of diminished rigidity of erection and impotence following surgery. These problems have been attributed to damage of the erectile nerves during penile surgery. Thus, it is sometimes more practical to treat severe cases of Peyronie's disease with placement of an artificial penile prosthesis following incision and release of the plaque.
The Authors
JAMES FITKIN, M.D.,
currently has a private practice in Grove City, Ohio. A graduate of the Ohio State University College of Medicine in Columbus, Dr. Fitkin completed a residency in family practice at Mount Carmel Health System, also in Columbus.GEORGE T. HO, M.D.,
is director of research in the surgery residency program and attending staff in the Department of Surgery, Division of Urology, in the Mount Carmel Health System. A graduate of Northwestern University Medical School, Chicago, Dr. Ho completed a residency in urology at Harvard Medical School, Boston, Mass.Address correspondence to George T. Ho, M.D., Mount Carmel Health System, 793 W. State Street, Columbus, Ohio, 43222. Reprints are not available from the authors.
REFERENCES
- Ehrlich HP. Scar contracture: cellular and connective tissue aspects in Peyronie's disease. J Urol 1997;157:316-9.
- Brock G, Hsu GL, Nunes L, von Heyden B, Lue TF. The anatomy of the tunica albuginea in the normal penis and Peyronie's disease. J Urol 1997;157:276-81.
- Devine CJ Jr. Introduction to the International Conference on Peyronie's disease. J Urol 1997;157: 272-5.
- Williams G, Green NA. The non-surgical treatment of Peyronie's disease. Br J Urol 1980;52:392-5.
- Devine CJ Jr, Somers KD, Jordan SG, Schlossberg SM. Proposal: trauma as the cause of the Peyronie's lesion. J Urol 1997;157:285-90.
- Van de Water L. Mechanisms by which fibrin and fibronectin appear in healing wounds: implications for Peyronie's disease. J Urol 1997;157:306-10.
- Jarow JP, Lowe FC. Penile trauma: an etiologic factor in Peyronie's disease and erectile dysfunction. J Urol 1997;158:1388-90.
- Desanctis PN, Furey CA Jr. Steroid injection therapy for Peyronie's disease: a 10-year summary and review of 38 cases. J Urol 1967;97:114-6.
- Somers KD, Dawson DM. Fibrin deposition in Peyronie's disease plaque. J Urol 1997;157:311-5.
- Rodriques CI, Njo KH, Karim AB. Results of radiotherapy and vitamin E in the treatment of Peyronie's disease. Int J Radiat Oncol Biol Phys 1995;31:571-6.
- Morales A, Bruce AW. The treatment of Peyronie's disease with parathyroid hormone. J Urol 1975;114:901-2.
- Davis CJ Jr. The microscopic pathology of Peyronie's disease. J Urol 1997;157:282-4.
- Zarafonetis CJ, Horran TM. Treatment of Peyronie's disease with potassium para-aminobenzoate (POTABA). J Urol 1959;81:770-3.
- Levine LA. Treatment of Peyronie's disease with intralesional verapamil injection. J Urol 1997;158: 1395-9.
- Rehman J, Benet A, Melman A. Use of intralesional verapamil to dissolve Peyronie's disease plaque: a long-term single-blind study. Urology 1998;51:620-6.
- Wahl SM. Inflammation and growth factors. J Urol 1997;157:303-5.
- Heslop RW, Oakland DJ, Maddox BT. Ultrasonic therapy in Peyronie's disease. Br J Urol 1967;39: 415-9.
- Carson CC. Potassium para-aminobenzoate for the treatment of Peyronie's disease: is it effective? Tech Urol 1997;3:135-9.
- Levine LA, Lenting EL. A surgical algorithm for the treatment of Peyronie's disease. J Urol 1997;158: 2149-52.
Retrograde Ejaculation
Alternative names
Return to topEjaculation retrograde
Retrograde ejaculation refers to the entry of semen into the bladder instead of going out through the urethra during ejaculation.
Causes and risks Return to top
Retrograde ejaculation may be caused by prior prostate or urethral surgery, diabetes, some medications, including some drugs used to treat hypertension and some mood altering drugs.
The condition is relatively uncommon and may occur either partially or completely. The presence of semen into the bladder is harmless. It mixes into the urine and leaves the body with normal urination. Men with diabetes and those who have had genitourinary tract surgery are at increased risk of developing the condition.
Maintaining good blood sugar control in diabetic men may be helpful in preventing the development of this condition. Avoiding the use drugs that cause retrograde ejaculation will prevent the condition developing as a result of their use.
A urinalysis performed on a urine specimen that is obtained shortly after ejaculation will reveal a large amount of sperm in the urine.
If retrograde ejaculation is caused by drugs, removal of the specific drug may resolve the condition. Retrograde ejaculation caused by diabetes or following genitourinary tract surgery may be responsive to the use of epinephrine-like drugs (such as pseudoephedrine or imipramine).
If retrograde ejaculation is caused by medications, discontinuation of the medication often restores normal ejaculation. If retrograde ejaculation is caused by surgery or diabetes, it is often not correctable.
The condition may cause infertility.
Call your health care provider if Return to top
Call for an appointment with your health care provider if you are having difficulty conceiving a child or you are concerned about retrograde ejaculation.
Update Date: 8/10/2001
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