Scar Tissue Can Lead to Painful Erections

You might think that a man who suffered an injury to his penis would be well aware of that fact. But for many men with Peyronie’s disease, repeated injury from sex or other physical activity causes damage without being noticed.

Peyronie’s is the formation of scar tissue, or plaque, in the erectile tissue of the penis that causes painful, curved erections. Men can only get Peyronie’s through trauma or injury, though Brad Figler, MD, an assistant professor of urology at the UNC School of Medicine, says most men don’t report either.

“The vast majority of patients don’t report a single traumatic episode,” Dr. Figler says. Because men with slight erectile dysfunction often get Peyronie’s, “during sex, the penis buckles a little bit because it’s not fully erect. It’s not painful and not something they notice, but it can cause a tear in the penis.”

It’s this kind of tear that can lead to the buildup of scar tissue.

The Symptoms of Peyronie’s

Here’s how Peyronie’s manifests:

“When there’s an injury, the body responds to that injury and can heal it with regular healthy tissue, which helps the penis expand, or it can heal it with scar tissue,” Dr. Figler says. “Scar tissue does a lot of good things—it prevents bleeding and infection—but it doesn’t expand.”

During an erection, a normal penis will expand in length and girth. But the presence of scar tissue will prevent expansion in one or both directions. “If the scar tissue prevents expansion in length, which is most common, then during an erection, one side of the penis gets long the way it used to, but the scarred side doesn’t. This length discrepancy causes curvature,” Dr. Figler says.

“The same thing can happen with girth: Normally, the penis increases in girth during an erection. If there’s scar tissue, the areas that don’t have scar tissue increase in girth like they used to, and the areas with scar tissue might not increase as much, and then the patient gets narrowing,” he says.

Although less common compared to penile curvature, the narrowing of the penis can cause other problems. Sometimes the narrowing can be so severe that it prevents blood flow behind the area of narrowing, or it can cause a “hinge effect,” which makes the penis unstable when erect.

While the injuries are often subtle and happen over time, Peyronie’s also can result from significant injuries, such as penile fracture, that lead to scarring. People who are prone to forming scar tissue—such as those who experience Dupuytren’s contracture, a similar condition in the fingers, or Ledderhose disease, a similar condition in the feet—are also more likely to get Peyronie’s.

How Peyronie’s is Treated

Peyronie’s disease is divided into two phases: active or stable.

For men in the active phase of Peyronie’s, there has been an injury to the penis that the body is trying to heal. During this phase, men will experience a deep throbbing in the penis, like they pulled a muscle, even when it’s not erect. Tenderness and curvature can also take place, though the degree of curvature might change as the body tries to heal the injury.

Men enter the stable phase of Peyronie’s if the curvature of the erect penis hasn’t changed for three to six months and there is also no pain from inflammation.

Treatment of Peyronie’s disease depends on the phase, but Dr. Figler says that all men’s erectile function should be assessed before deciding on any treatment. “Some of these patients have such severe erectile dysfunction that if we fix the curvature or narrowing, it won’t be any better since they still can’t get an erection,” he says.

For men in the active phase, Dr. Figler says the condition must run its course. “We’ll treat it symptomatically with ibuprofen or Advil, and then essentially wait until that phase is over,” he says.

Treatment of the stable phase of Peyronie’s can be more in-depth. Medication can be injected into the scar tissue to dissolve it or surgery can be performed.

“If you think about a patient with curvature, one side of the penis is longer during an erection than the other side. To treat the curvature, we’re either going to make the short side of the penis longer, or the long side of the penis shorter,” he says.

Surgery that makes the long side of the penis shorter, called plication, is minimally invasive, with the whole procedure taking less than an hour. Doctors operate on the healthy side of the penis and make a small incision over the point of maximal curvature. A pleat is put in the erectile tissue to shorten it and make both sides of the penis the same length, which eliminates the curvature.

Incision grafting, or the procedure that makes the shorter side of the penis longer, is more invasive. Doctors operate on the side of the penis with the scar tissue, either removing it or making small incisions to allow it to expand. As a result, the penis straightens out, “but then there is a defect, as there is no covering to the erectile tissue where the plaque was removed or incisions were made,” Dr. Figler says. The area is then covered with a graft, or tissue, to fix the defect.

Because grafting is more invasive, Dr. Figler says the ideal candidate for this procedure must have severe curvature or narrowing and good erectile function. “We can treat even severe curvature in the other surgery, but we can’t treat narrowing in that surgery,” he says. “If someone wanted to treat severe narrowing, they would need a graft.”

A penile prosthesis can be also implanted for men who have severe erectile dysfunction and Peyronie’s. “If someone has Peyronie’s disease and severe erectile dysfunction, then we can go straight to the penile prosthesis (to help the man get erections) because just the act of putting the prosthesis in straightens the penis out,” Dr. Figler says.

The Psychological Aspects

Penile issues such as erectile dysfunction can often cause embarrassment or shame in many men, and Peyronie’s is no different. Dr. Figler says the psychological aspect of the disease is a huge problem, especially as it relates to self-image and talking to a doctor.

“We know that it definitely affects men’s self-image, and they are definitely reluctant to seek medical attention,” he says. “We also know that when they do seek attention, it can take a long time for them to get referred to a place where they can get treatment.”

That said, Dr. Figler says there has been a change in recent years thanks to Xiaflex, a medication that helps treat Peyronie’s. “I think there’s a growing perception among men who have seen the Xiaflex advertisements, as well as with primary care doctors, that this is a treatable disease,” he says. “Whereas, if you asked primary doctors a decade ago, they’d say there is nothing we can do about it, even though that wasn’t correct. Nowadays, there is a better sense that this is treatable.”

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