Peyronie's disease is scar tissue in the wrong place. The penis is built around two cylinders of spongy tissue wrapped in a tough elastic sheath called the tunica albuginea. When that sheath is injured, usually by repeated minor trauma during sex that a man may not even notice, it can heal with a plaque of inelastic scar instead of normal tissue. During an erection everything else stretches and the plaque does not, so the penis bends toward it. Depending on where the plaque sits, the result is a curve upward, downward or to the side, an indentation or hourglass narrowing, a loss of length, and often pain in the early months.
At NYMD Center we treat Peyronie's disease with the least invasive approach that will work, and for most men that is a course of collagenase injections, marketed as Xiaflex, combined with stretching and modeling between treatments. In Dr. Shusterman's hands this works well. One representative case is a man with a curve of more than 30 degrees whose bend was reduced to about 10 degrees over two rounds of treatment, enough to restore comfortable intercourse without surgery. Surgery is reserved for severe curvature and for men who do not respond to injections.
Who it affects and the symptoms that bring people in
Peyronie's disease most often appears in middle age, though it can occur at any age. Men with diabetes, a family history, or Dupuytren's contracture in the hands (a related scarring disorder) are more prone. A specific injury is remembered by some men and not by most.
The disease has two phases. In the active phase, lasting roughly six to eighteen months, the plaque is forming: there may be pain with erections, a lump that can be felt under the skin, and a curve that is changing from month to month. In the stable phase the pain fades, the plaque hardens and the deformity stops changing. Men usually come in for one of three reasons: the bend has become bad enough to make sex difficult or impossible for one or both partners, the pain, or worry about what the lump is. Erectile dysfunction often accompanies Peyronie's, partly from the plaque interfering with the mechanics of the erection and partly from the same vascular factors that damaged the tissue in the first place.
How we evaluate it at NYMD Center
The evaluation begins with history: when the curve started, whether it is still changing, whether there is pain, and how it affects sex. We ask you to photograph the erect penis at home from the top and the side, which documents the degree and direction of the curve better than any description. On examination we feel for the plaque and note its size and position.
When needed, we perform a penile duplex ultrasound in the office after an injection that produces an erection. This shows the plaque, any calcification within it, and the blood flow into and out of the penis, which tells us whether erectile dysfunction is part of the picture and what will and will not work. Calcified plaques respond less well to injections, and poor blood flow changes the surgical options, so this study shapes the plan. Blood work, including glucose and testosterone, rounds out the assessment.
Treatment options
Observation in the active phase
Mild curvature that does not interfere with sex and is not painful can be watched. Some plaques soften on their own and a minority of curves improve. Anti-inflammatory medication helps pain in the active phase. Oral supplements and vitamin E are widely sold for Peyronie's; the evidence for them is weak and we do not rely on them.
Traction and modeling
A penile traction device worn daily during the active phase can limit the loss of length and modestly reduce curvature. It requires a real time commitment, usually hours a day for several months, but it is non-invasive and it complements the injections below.
Collagenase (Xiaflex) injections
Collagenase is an enzyme that breaks down the collagen in the plaque. It is injected directly into the plaque in the office, in cycles of two injections a few days apart. Between cycles you perform gentle modeling, stretching the penis against the curve, and we recommend traction. A full course is up to four cycles, and many men see a meaningful reduction in curvature by the second or third. The injections are given to men with a stable curve of 30 degrees or more and a plaque that can be felt. Bruising and swelling for a week or two are expected. The serious risk, rare but real, is a tear of the tunica during an erection in the days after an injection, which is why we ask you to avoid sex for a specified period after each cycle.
Insurance coverage for Xiaflex is sometimes denied on first submission. We appeal, with documentation of curvature and the effect on function, and most appeals succeed. When they do not, we enroll you in the manufacturer's patient-assistance program, which has covered treatment for a number of our patients.
Surgery
For severe curvature, hourglass deformity that buckles during intercourse, or failure of injection therapy, surgery straightens the penis. Plication shortens the longer side to match the plaque side; it is reliable and preserves erectile function but costs some length. Plaque incision and grafting lengthens the short side; it preserves length but carries a higher risk of erectile dysfunction afterward. For men who also have significant erectile dysfunction, a penile implant placed with straightening maneuvers corrects both problems at once. We discuss these honestly, including what each costs in length and function, and refer to or perform them only when the less invasive options have been exhausted.
What to expect at your visit
Bring your photographs and a list of medications, and expect a frank conversation about your sex life; that is the point of the visit. The exam and, if needed, the ultrasound are done in the office. If injections are planned, we submit for insurance authorization before the first cycle. Each injection visit takes about fifteen minutes, and you leave with a dressing, modeling instructions, and clear guidance on when sex can resume. We measure the curve at the start and after each cycle so progress is documented rather than guessed at, and we treat any erectile dysfunction alongside, from shockwave therapy to medication.
When to seek care urgently
A sudden pop, sharp pain and rapid swelling or bruising during an erection, particularly in the days after an injection, can mean a tear of the tunica and needs same-day evaluation. Call us; after hours, go to an emergency department and tell them you are being treated for Peyronie's disease.
Questions patients ask
Will Peyronie's disease go away on its own?
Sometimes, but not usually. A minority of mild curves improve during the active phase, and pain almost always fades once the plaque stabilizes. The curvature itself generally persists. If the bend interferes with sex, treatment in the stable phase is more effective than waiting for a change that may not come.
How well do Xiaflex injections work?
Well, in our experience, for men with a stable curve of 30 degrees or more and a plaque that can be felt. A representative case in our practice went from more than 30 degrees to about 10 degrees over two cycles. Results vary, calcified plaques respond less, and traction and modeling between cycles matter. Most men who respond do so by the second or third cycle.
What if my insurance denies Xiaflex?
Denials on first submission are common. We appeal with photographs, measured curvature and documentation of how the deformity affects function, and most appeals are approved. When an appeal fails, we enroll you in the manufacturer's patient-assistance program, which has covered treatment for a number of our patients. You should not have to give up on treatment over paperwork.
Is surgery ever the right first choice?
For a small number of men, yes: severe curvature, an hourglass deformity that buckles during sex, extensive calcification that will not respond to injections, or significant erectile dysfunction that needs an implant anyway. For most men, injections and traction come first, and surgery is held in reserve for those who do not get enough benefit.
Does Peyronie's disease cause erectile dysfunction?
Often the two go together. The plaque can let blood escape during an erection and interfere with rigidity, and the vascular conditions that make the tunica vulnerable to injury also impair blood flow. We assess both at the same visit, often with a penile duplex ultrasound, and treat the ED alongside the curvature.
Make an appointment
Manhattan (212) 991-9991 · Forest Hills (718) 360-9550 · same-week visits, most major insurance accepted.