Peyronie’s Disease (Bending of the penis)




Peyronie’s disease is a disease characterized by the formation of fibrous plaques at the covering layer of the penis (tunica albuginea) resulting in the bending of the penis towards the direction of the plaque during erection. As a result of this, when the penis achieves erection, it is unable to stretch on the side of the plaque, resulting in the bending of the penis towards to the side of the plaque.

Images from West Suffolk NHS Foundation Trust

It may cause pain in the early inflammatory stages of the disease.

The curvature or bending of the penis during erection may be disfiguring, and even painful during the early stages of the disease until the plaque becomes stable.

Clinical manifestations include curvatures and hourglass deformities.

Not all bending of the penis is due to Peyronie’s disease. The other causes bending of the penis include:

  1. Injury to the penis.
  2. Autoimmune disorders.
  3. Inherited fibrous tissue (collagen) abnormality.

Congenital penile curvature (chordee) – this is a condition when a boy is born with and is only apparent when the baby’s penis is erect. Unlike Peyronie’s disease which also involves curvature of the penis, the condition isn’t caused by scar tissue.

Difference between Peyronie’s disease and penile curvature

Peyronie’s disease is one type of penile curvature that happens to adults. Some men can be born with penile curvature and this is called congenital curvature or chordee. It is not caused by scar tissue, and the condition does not change over time. It might not be noticeable until after puberty when a man begins having more regular erections.


Peyronie’s disease and erectile dysfunction

Peyronie’s disease is known to be associated with erectile dysfunction, and approximately 30% of patients with Peyronie’s disease will also have diabetes. Peyronie’s disease has a significant association with obesity, hypertension, hyperlipidaemia, smoking and pelvic surgery. It has been noted to affect 16% of patients after radical prostatectomy. An association with Dupuytren’s disease is also well recognized.


How common is Peyronie’s disease?

Experts estimate that about 6% to 10% of men between ages 40 and 70 have Peyronie’s disease. It’s been observed in other ages, but it’s less common.


Causes and risks

Curvature of the penis develops from the rigid covering of the penis, the inelastic tunical scar, secondary to macro-/microtrauma (injuries) in individuals either predisposed genetically or with an underlying disease process. This condition can cause severe psychological, mental, and physical stress.

It may cause pain, erectile dysfunction (impotence), and curvature/defect caused by the plaque. It can prevent proper sexual intercourse, resulting in embarrassment and frustration.

The actual cause on why Peyronie’s disease occurs is still unknown. 

Risk factors include the following:

Heredity: If a family member has Peyronie’s disease, you have an increased risk of the condition.

Connective tissue disorders: Men who have certain connective tissue disorders appear to have an increased risk of developing Peyronie’s disease. For example, a number of men who have Peyronie’s disease also have a cordlike thickening across the palm that causes the fingers to pull inward (Dupuytren’s contracture).

Age: Peyronie’s disease can occur in men of any age, but the prevalence of the condition increases with age, especially for men in their 50s and 60s. Curvature in younger men is less often due to Peyronie’s disease and is more commonly called congenital penile curvature. A small amount of curvature in younger men is normal and not concerning.

Prostate cancer: Men who have had surgery for prostate cancer are at an increased risk.

Autoimmune disorders: If you have an autoimmune disorder like lupus, you’re more likely to get Peyronie’s disease.


The phases in the natural history of Peyronie’s Disease

Peyronie’s disease is characterized by two separate phases.

  1. The active (acute) phase is characterized by a painful and evolving plaque, inflammation, and progression of the curvature. This usually lasts 6 to 18 months. Approximately 10% of patients will have improvement in their disease. The majority of patients will experience maintenance or worsening of the defect. You may feel pain when your penis is erect or when it is soft.
  2. The chronic phase is when the plaque stops growing and the penis doesn’t bend any further. If there was pain with erection during the acute phase, it often will have ended by this time. The pain will usually be gone by this time, but sometimes it can continue, especially with erections. Also, erectile dysfunction (ED) or problems getting or keeping the penis hard may develop.

Once the disease has been stable for approximately 6 months, this is considered the stable (chronic) phase, at which time surgical treatment will be appropriate.

Surgery is not recommended until the symptoms have persisted for one or two years.



Patients with this condition describe the curvature of the penis during erection. In the early acute phase, it may be painful and there is progressive curvature.

The scar tissue or plaque can be felt under the skin of the penis as flat lumps or a band of hard tissue.

Your penis might curve upward or downward or bend to one side.

You may have problems initiating or maintaining an erection (erectile dysfunction).

Your penis might become shorter as a result of Peyronie’s disease.

You might have penile pain, with or without an erection.

Sometimes other deformities may be present, the erect penis might have narrowing, indentations or even an hourglass-like appearance, with a tight, narrow band around the shaft.

The curvature and penile shortening associated with Peyronie’s disease might gradually worsen. At some point, however, the condition typically stabilizes after three to 12 months or so.

Pain during erections usually improves within one to two years, but the scar tissue, penile shortening and curvature often remain.


Your doctor will take a medical and sexual history which is typically enough to establish a diagnosis of penile curvature. It may also be helpful for your doctor to examine your penis while erect. This can be done after an injection of vasoactive drugs to prompt an erection. It is best to bring along a photo of the penis while in erection, denoting the curvature.

The hard plaques can most often be felt whether the penis is stiff or not.

Your doctor may recommend an ultrasound. The ultrasound will reveal where the plaque is, check for calcium buildup and show how the blood flows in your penis. This test can allow your doctor to determine which treatment options you might be a candidate for.


Complications of Peyronie’s disease may include:

Inability to have sexual intercourse

Difficulty achieving or maintaining an erection (erectile dysfunction)

Anxiety or stress about sexual abilities or the appearance of your penis

Stress on your relationship with your sexual partner

Difficulty fathering a child, because intercourse is difficult or impossible

Reduced penis length

Penile pain


Patient evaluation

Diagnosis of Peyronie’s disease is readily made by a typical history and penile examination. Clinically important information includes:

  1. stage of the disease (ie active versus chronic)
  2. curvature features (ie direction, degree)
  3. penile length and other associated penile deformities (eg hourglass deformity)
  4. Presence of pre-existing or co-existing erectile dysfunction.

Short disease duration (<12 months), ongoing penile pain and continuing changes in penile deformity are likely indications of the acute phase.

Physical examination in the flaccid state will often disclose an indurated area or an obvious penile plaque, even though patients may be unaware of it.

However, evaluation of a flaccid penis is inadequate when evaluating Peyronie’s disease deformity – the degree of angulation is not fully appreciated and patients tend to overestimate the degree of angulation.

Commonly, the curvature direction corresponds with the location of the plaque. In two-thirds of patients, the plaque is positioned on the dorsal surface of the penis. Lateral and ventral plaques are less common but are more likely to impair penetration. Multiple plaques located on opposite sides of the penis, or plaques appearing in the septum, may result in penile shortening with a relatively straight penis.


Investigations in Peyronie’s disease

Generally, diagnosis of Peyronie’s disease is based on clinical findings.

You may require a duplex Doppler ultrasound combined with an intracavernosal vasoactive agent. This allows your doctor to objectively measure your penile blood flow parameters, the penile curvature and other deformities, and plaque characteristic (eg calcification). These parameters can help direct treatment options.

Magnetic resonance imaging (MRI) is very rarely indicated and should only be organized by your specialist.



Doctors often suggest waiting 1 to 2 years or longer before they try to correct it.

Mild cases of the condition rarely need treatment. Also, the pain that comes from Peyronie’s disease happens only with an erection and is usually mild. If it’s not causing a problem with your sex life, treatment may not be necessary.

In a very few cases (about 13 out of 100), Peyronie’s disease goes away without being treated. Men with small plaques, not much curving of the penis, no pain and no problems with sex may not need to be treated.

Much of the medical treatment for Peyronie’s disease remains non-standardized. Various treatment have been tried.

Drug therapy may help men who are badly affected by the disease during the acute phase. Most society guidelines do not recommend oral drugs because long-term studies have not shown convincing benefit.

Medical treatment include vitamin E (Tocopherol), aminobenzoate potassium (Potaba), colchicine, tamoxifen, intralesional injection therapy with verapamil, interferon, and steroids. Medical treatments have been plagued with flawed results, poorly designed studies, and conflicting data.

Surgery still remains the mainstay in treatment. 

Once the surgeon has determined that the plaque is stable and painless, a surgical approach can be taken.


Non-surgical treatment:

Most society guidelines do not recommend oral drugs because long-term studies have not shown convincing benefit. These have been plagued with flawed results, poorly designed studies, and conflicting data.

Non-surgical treatments may include oral medications, injections and investigative therapies. They may not necessarily work. It is best you discuss with your doctor on this issue.

Oral Medications

There is no oral agent that cures Peyronie’s disease and most of the commonly used treatments that patients ‘source’ from, or investigate on the internet, have had no efficacy in proper clinical trials. If oral agents are to have any benefit, these probably need to be instituted very early in the disease process, but there is significant doubt that any offer real benefit. In addition, these oral agents are ‘off-label’ when treating Peyronie’s disease exclusively.

There is no strong evidence to date that supports the use of oral monotherapy for Peyronie’s disease. The AUA and CUA guidelines on Peyronie’s disease recommend against oral therapy with vitamin E, tamoxifen, omega-3-fatty acids, procarbazine and vitamin E/L-carnitine combination

Oral medications that have been used for the treatment of Peyronie’s Disease include the following:


Pentoxifylline is a nonspecific phosphodiesterase inhibitor that may increase penile levels of nitric oxide and may prevent, or reverse, calcification of the Peyronie’s plaque.

However, this drug is usually taken three times per day and has gastrointestinal side effects, which limits its use.

Phosphodiesterase type-5 inhibitors

Phosphodiesterase type-5 (PDE5) inhibitors are sildenafil, tadalafil and vardenafil. Animal studies have found that these drugs, which are designed to augment erections, can reduce the collagen or smooth muscle and collagen III–I ratios in the Peyronie’s disease-like plaque.

In a retrospective controlled study, daily tadalafil (5 mg) resulted in statistically significant resolution of septal scar in 69% of patients, compared with 10% in the control group.

As there is often co-existing erectile dysfunction in patients with Peyronie’s disease, low-dose PDE5 inhibitors for acute-stage Peyronie’s disease may be recommended, although we advise patients that evidence for the use of these agents is poor.

Vitamin E
Vitamin E has been used to treat Peyronie’s Disease since 1945. It is a useful anti-oxidant and is also used in treating scars.

Potassium para amino benzoate also known as Potaba may have effective results if used in large doses. This may however, cause intestinal illness.

Colchicine is widely used in treating gout. It helps in reducing inflammation and fights against the production of scar tissues.

Tamoxifen is a non-steroidal medication that is anti-estrogen. It is used in the treatment of a condition similar to Peyronie’s disease, known as desmoid tumors.

Carnitine is an antioxidant that aims to decrease inflammation and reduce abnormal healing of wound.

Penile Injections
Penile injections allow the direct appliance of drugs into the plaque and are effective when used in high doses. A local anesthesia may be administered before the injection is given to the patient. It is a minimally invasive method of treating Peyronie’s Disease. Patients who have other diseases or who are unwilling to undergo surgery may use penile injections.

Verapamil is administered as a direct injection that stops the production of scar tissue precursors. It is used in treating high blood pressure. The production of collagen is known to be stopped by using Verapamil. Studies show that Verapamil is successful in treating penile curvature and pain. Research is still ongoing on this drug.

Researchers are working on the effectiveness of Collagenase to disrupt formation of the plaque of Peyronie’s disease.

Interferon Injections
Interferon is a protein produced in the body. It is used in treating keloid scars and scleroderma.

Penile injection therapy

Pics from Semantic Scholar

Investigative Therapies
These are only investigative, and are not part of the treatment for Peyronie’s disease.

Therapies that are being researched for the treatment of Peyronie’s disease are:

  1. High-intensity Ultrasound
  2. Shock-wave treatment
  3. Hyperthermia
  4. Radiation therapy
  5. External penile traction therapy



Surgery remains the gold standard for correcting penile deformity. Surgery is indicated when the patient has:

  1. stable disease
  2. minimal-to-no pain
  3. difficulty with or inability to engage in sex because of the deformity
  4. desire for the most rapid and reliable result

Surgery is reserved for men with more severe, disabling penile deformities that make it hard to have sex. Most doctors suggest putting off surgery until the plaque and curving have stopped getting worse and the patient has shown no worsening for at least 9 to 12 months.

Indications for surgical therapy include disease duration >12 months, stable phase of Peyronie’s disease >6 months, and inability of the patient to perform sexual intercourse due to the extent of penile deformity including curvature and/or hinge effect.

The aim of surgery is to correct curvature to allow a ‘functionally’ straight erection. This equates to a curvature of <20°, which is usually sufficient to allow for satisfactory intercourse. Some patients may request surgery for psychological or body image reasons, even with lesser curvatures. 


Surgery is performed in three approaches:

Surgery to cut down the part of the penis that is opposite to the plaque or curvature

Surgery to elongate the part of the penis that is curved

Surgery to place penile prosthesis in complex cases


Surgical therapy of Peyronie’s disease is subdivided into three main procedures:

  1. plication techniques;
  2. grafting techniques with partial plaque excision or incision followed by defect closure of the tunica albuginea with various grafts; and
  3. Correction of deformity with simultaneous penile prosthesis implantation in patients with ED not responding to medical therapy

The Leriche technique uses an 18 gauge needle to cut the plaque. It is known to be effective in decreasing the curve and providing sexual function.

Grafting techniques to correct penile deformity are applied when curvature exceeds 60°, as these procedures may preserve penile length by elongating the concave side of curvature.

Besides a curvature of >60°, grafting techniques are also indicated when patients experience a shortened penis, to avoid further shortening after plication.

Moreover, the presence of an hourglass deformity with associated hinge effect represents another indication for a grafting technique.


Penile plication:

This approach is indicated for those men with relatively mild-to-moderate curvature (<60–70°), satisfactory preoperative erections with or without oral therapy, and the absence of penile instability (i.e. buckling when axial pressure is applied to the penis such as during penetrative sexual intercourse).

Since penile plication is considered a tunical shortening procedure, it is not recommended for patients with shorter penile lengths. Penile shortening may occur, but most patients do not report enough shortening to prevent sexual intercourse.  The majority of patients having shortening of <1 cm. 

Despite multiple advances in penile plication procedures, its applicability to Peyronie’s disease is still limited. Those with complex deformities such as hourglass deformities, lateral indentations, or curvatures >60–70° may not be appropriately treated with this technique

Nesbit operation

This involves shortening of the longer side of the penis, thus it is a shortening procedures for the treatment of penile curvature. It is basically a plication procedure.

It is technically simple, minimal surgical risk, and result in quick patient recovery.

16- or 24-dot minimal tension technique, which is currently the most popular and most performed tunical shortening method for the treatment of Peyronie’s disease.

The Nesbit operation may be performed by extremely specialized urological surgeons who are skilled in techniques used for corrective surgeries.


What does Nesbit’s procedure involve?

  • You will be given either a general anesthesia (you’ll be asleep) or spinal anesthesia (awake but numb from the waist down).
  • Your consultant urologist will simulate an artificial erection during the operation to confirm the degree of deformity
  • To correct the deformity, your consultant will deglove your penis, exposing the tissue. At the point of curvature, a wedge incision in the tissue is made, on the opposite side to the curvature. This will then be stitched to straighten the penis
  • The unaffected side of the penis is shortened to straighten your penis. In some cases, circumcision may also be performed at the same time to improve the outcome of the procedure.

The 16- or 24-dot minimal tension technique

Incision or excision of the plaque and patch grafting

This is considered a tunical-lengthening procedure for the treatment of Peyronie’s disease.

The candidates for this treatment of incision or excision of the plaque and patch grafting procedure includes:

  1. Patients with good erectile function with complex curvatures,
  2. those with >60° defects,
  3. destabilizing hinge defects, and/or shorter phallus


Types of grafts used include autologous, synthetic, and non-autologous grafts

Dermis, tunica vaginalis, buccal mucosa, saphenous vein, temporalis fascia

Gortex, silastic, Dacron

Pericardium, dermis, fascia lata, dura mater, and dermis.

These are divided into two groups: allografts and xenografts.

Currently, the two most popular non-autologous xenografts are pericardial and small intestinal submucosa grafts.

They include:

Tutoplast (human pericardium)

Surgisis ES (small intestine submucosa)
Xenform (acellular dermal matrix)

Pics from Semantic Scholar, The Journal of Sexual Medicine

Surgery to place penile prosthesis in complex cases

This is used in correction of deformity with simultaneous penile prosthesis implantation in patients with Erectile Dysfunction not responding to medical therapy

Pic from the Journal of Sexual Medicine

Risks of the procedures

Some degree of erectile dysfunction, increase in patient discomfort, and some reported loss of penile tactile sensation 

Persistent or recurrent curvature, diminished sensation at the glans penis, diminished erectile function, or penile shortening.

More common risks include:

Shortening of the penis (this is due to the fact that the healthy tissue on the opposite side to your curvature is incised. Shortening has also already occurred prior to surgery due to the scarring from the Peyronies Disease)

Dissatisfaction with the cosmetic or functional result

Temporary swelling or bruising of the penis and scrotum occasionally lasting up to two weeks.

Less common risks include:

No guarantee that the bend will be completely corrected

Future recurrence of the condition

Bleeding or infection

Impotence or difficulty maintaining erections.


When to see your doctor

If you notice a curve in your penis – especially one that gets worse over time.

Look for the signs that you may have plaque building up under the skin of your penis:

  1. Your penis is shorter.
  2. Your penis is bent/curved.
  3. There are lumps in your penis.
  4. Erections are painful.
  5. Erections are soft.
  6. Sex is difficult because of the bend.
  7. There is a loss of girth, an indentation, or an hourglass appearance of the penis.


How long does the procedure take?

The procedure itself takes approximately 1.5 to 2 hours, dependent on the severity of the curvature.


Going home and recovery

You may experience discomfort, swelling and bruising for a few days after the procedure

Painkillers will be given to you to take home

Dissolvable stitches are normally used at skin level and do not require removal

A catheter may need to be inserted into the bladder for 24 hours after the operation, to prevent any problems with passing urine

Once the catheter has been removed and you are passing urine normally, you will be able to go home

The average hospital stay is 2-3 nights

It is advisable to try and elevate your penis with padding or gauze to help alleviate swelling and bruising

We advise that you should abstain from sexual penetrative intercourse for six weeks

Having normal erections during this time is normal and advised

We do suggest that you have someone drive you home if you are going a fair distance.


How long will it take to heal?

Every person is different with regards to healing, but you may find it can take up to two weeks for swelling and bruising to settle. The sutures can take approximately few weeks to dissolve and any wound issues will be picked up during your follow-up.


When will I notice results?

Most men with normal erections will notice results straight away.


What are the risks of the Nesbit’s procedure?

Every surgical procedure carries some degree of risk. Nesbit’s procedure has several potential risks, some more common than others.

More common risks include:

Shortening of the penis (this is due to the fact that the healthy tissue on the opposite side to your curvature is incised. Shortening has also already occurred prior to surgery due to the scarring from the Peyronies Disease)

Dissatisfaction with the cosmetic or functional result

Temporary swelling or bruising of the penis and scrotum occasionally lasting up to two weeks.

Less common risks include:

No guarantee that the bend will be completely corrected

Future recurrence of the condition

Bleeding or infection

Impotence or difficulty maintaining erections.


Making the right decision

So that you know exactly what to expect from the results of this surgery, we encourage you to share your expectations with your doctor as early as possible. This should help you to establish a clear indication of what is realistically achievable with this procedure.

Do not be pressurized to make a decision. To give yourself time to decide what’s right for you, we recommend you leave at least 2 weeks between your consultation and booking your surgery so that you can make a proper informed decision.


After Treatment

A light pressure dressing is often left on the penis for 24 to 48 hours after surgery to help with the healing process.

During surgery, a tube (catheter) will have been placed through the end of the penis into the bladder and this may still be in place when you wake up.

The tube is often removed at discharge.

You may be given antibiotics to take for a few days to lower the risk of infection and help keep swelling down, as well as pain medications. You should not have sex for at least 6 weeks after surgery.