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Peyronie's Disease

Peyronie's disease (PD) is an acquired fibrosing disorder of the tunica albuginea of the corpora cavernosa that produces palpable plaque, penile deformity (curvature, hinge, hourglass, indentation), pain on erection, shortening, and — in a substantial minority of men — concurrent erectile dysfunction. It sits at the intersection of sexual dysfunction, functional reconstruction, and a fibrotic disease family that also includes Dupuytren contracture and plantar (Ledderhose) fibromatosis.[1][2]

Contemporary prevalence estimates range from 1–20% depending on population and ascertainment method, with mean age of onset of 53 years. Many men remain undiagnosed due to embarrassment and the mistaken belief that no treatment exists.[3]

Management is governed by the 2015 AUA Peyronie's Disease Guideline, the 2025 EAU Male Sexual Health Update, and the 2026 BJU Guideline-of-Guidelines synthesis.[4][5][6]

This page gives the overview of diagnosis, non-surgical management, and the surgical algorithm. For deep dives into each surgical pathway, see the subsection articles:

  • Tunica PlicationShortening procedures for curvature ≤60° with preserved EF — Nesbit, modified Nesbit (tunical shaving), Yachia (vertical-to-horizontal), Lue 16-dot, iterative 8-dot, TAP — technique-specific outcomes, complications, and recent developments (penoscrotal incision, buried knots, plaque thinning for length preservation).
  • Plaque Incision / Excision with GraftingLengthening procedures for curvature >60° or complex deformity — partial excision vs. relaxing incision, the Hatzichristodoulou collagen fleece sealing technique, graft materials (buccal mucosa, bovine/cadaveric pericardium, collagen fleece, SIS, tunica vaginalis, dermis, SV), outcomes after CCH failure, PEG + supplemental plication for compound curvature.
  • Penile Prosthesis with Adjunctive StraighteningIPP for PD + ED refractory to medical therapy — the full adjunctive ladder (manual modeling 75% of cases, scratch technique, tunical plication 5%, grafting / PICS technique 2%), extended corporal dilation to reduce modeling need, hemostatic patch vs. pericardium for IPP grafting, long-term satisfaction predictors.
  • Manual Modeling — Wilson TechniqueStep-by-step technique for the first-line adjunctive maneuver during IPP: Wilson 1994 original series, Lucas "optimal modeling" update (90-second intervals, glanular pressure, 47.8° → 10.6°), Moncada home modeling protocol (94.7% ≤10° at 6 months), urethral perforation prevention.
  • Scratch Technique & Endocavernosal Plaque DisruptionEndocavernosal plaque disruption through the corporotomy — avoids degloving and NVB mobilization. Antonini IPP + scratch + 24-week vacuum therapy protocol (residual 7–9° across plaque locations). Shaeer's punch technique: transcorporeal plaque excision with 85% operative time reduction vs. excision-grafting.

Disease Phases​

The distinction between phases is operationally critical — it determines what treatments are appropriate.

PhaseDurationFeaturesManagement focus
Acute / activeOnset through ~12–18 monthsPainful erections; evolving deformity; inflammation; plaque formationMedical / intralesional / mechanical therapy; surgery contraindicated
Chronic / stableAfter ~12–18 monthsPain resolved; deformity fixed; plaque may calcifySurgical correction if deformity interferes with function

Stability is defined clinically as: (1) no change in curvature for 3–6 months, (2) absence of pain on erection, and (3) time from onset beyond 12 months. All three should be present before offering surgery.[4]

Pathophysiology​

The current working model: repetitive microvascular trauma to the tunica albuginea during buckling of the erect or semi-erect penis (intercourse being the most common context) triggers a dysregulated wound-healing response in genetically predisposed men.[2][7][8]

Cascade​

  1. Initiating injury — microtears in the tunica albuginea with extravasation of plasma proteins
  2. Inflammatory phase — fibrin deposition, macrophage recruitment, IL-1 / IL-6 / TGF-β overexpression, elastase release
  3. Proliferative phase — fibroblast and myofibroblast recruitment; aberrant extracellular matrix deposition
  4. MMP/TIMP imbalance — elevated TIMPs and suppressed MMPs tilt the matrix toward deposition rather than remodeling[8]
  5. Collagen remodeling — tunical collagen shifts from predominantly type I to type III
  6. Chronic plaque formation — densely fibrotic, often mineralized over time

Genetic and comorbid associations​

  • Dupuytren contracture — shared fibroblast and myofibroblast biology; coexists in ~10–20% of PD patients
  • Plantar (Ledderhose) fibromatosis — less common but overlapping
  • Diabetes, hypertension, dyslipidemia — modest associations; may reflect shared vasculopathic / inflammatory substrate
  • Low serum testosterone — associated but causal role unclear
  • Prior pelvic/prostate surgery — post-prostatectomy PD is a recognized entity
  • Pelvic radiation — rare but reported association

Clinical Presentation​

Symptoms​

  • Penile curvature — direction and degree vary; dorsal is most common (~70%), lateral ~20%, ventral <10%; bidirectional or complex in 10–15%
  • Palpable plaque — often dorsal, 1–3 cm typical; may be linear, nodular, or sheet-like
  • Penile pain — present in ~45% at onset; resolves in the majority by 12 months regardless of treatment
  • Penile shortening — nearly universal; averages 1–4 cm
  • Complex deformity — indentation, hinge effect (buckling at a focal point), hourglass, biplanar curvature
  • Erectile dysfunction — concurrent in 30–50% of patients; may be pre-existing or a consequence of disease
  • Psychosocial distress — depression, relationship strain, body-image distress in >80% of patients[4][9]

The patient conversation​

Men with PD consistently report feeling that providers dismissed their concerns or failed to appreciate the functional and psychological impact. A complete Peyronie's assessment begins with the patient's description of how the deformity affects intercourse, confidence, and relationships — not with a measurement.

Evaluation​

Minimum diagnostic workup (AUA)​

  • Detailed history — deformity onset, progression, precipitating trauma, pain, interference with coitus, prior treatments, erectile function (SHIM / IIEF-5)
  • Physical examination — palpation of flaccid penis for plaque location/size, circumcision status, stretched penile length
  • Validated questionnaires — PDQ (Peyronie's Disease Questionnaire) and IIEF

Objective assessment​

  • Intracavernosal injection (ICI) test — gold standard for erect-state assessment. Trimix or alprostadil induces full erection; curvature is measured with a goniometer along each plane; plaque palpation is most informative with the penis erect.[4][10]
  • Penile Doppler duplex ultrasound + ICI — measures plaque size/density, identifies calcification, and assesses cavernosal arterial inflow + veno-occlusive function. Especially valuable when concurrent ED is suspected.
  • Patient-provided photographs — of the maximum erection, in multiple planes, are useful for both measurement and longitudinal tracking.

Imaging​

Routine MRI is not required. Selective MRI for complex biplanar deformity, atypical plaque, or revision planning.

Natural History​

Untreated PD trajectories (Levine & Mulhall registries; Ziegelmann review):[3][9]

  • Curvature stabilizes or worsens in ~90%; spontaneous resolution is rare (<12%)
  • Pain improves or resolves in >80% by 12–18 months
  • Penile length progressively shortens in the absence of intervention
  • Erectile function tends to worsen over time
  • The notion that "it will go away on its own" is not supported by the data

Non-Surgical Management​

Oral therapies — limited evidence​

No oral monotherapy has robust evidence of efficacy.[1][4] Agents historically used include vitamin E, pentoxifylline, colchicine, tamoxifen, and potassium paraaminobenzoate (Potaba). Meta-analysis data do not support their use as monotherapy; they are considered adjuncts at best.

Intralesional injection therapy​

Collagenase clostridium histolyticum (CCH / Xiaflex) — the only FDA-approved intralesional therapy for PD.[11][12]

ParameterDetail
IndicationStable PD with palpable plaque and curvature 30°–90°
ProtocolUp to 8 injections × 10,000 U over 24 weeks, in 4 cycles of 2 injections separated by 24–72 hours
ModelingClinician modeling after each cycle (48–72 hours post-injection); patient self-modeling 3×/day between cycles
EfficacyMean curvature reduction ~17° (CCH) vs ~9° (placebo); net benefit ~8° (IMPRESS I & II)
Adverse eventsEcchymosis, penile swelling, pain, localized hematoma; corporal rupture / fracture in ~0.5% — a defining injection-specific risk
ContraindicationsVentral curvature (proximity to urethra), plaque at the base (proximity to penile bone anchoring), inability to perform home modeling

Interferon α-2b — modest evidence for curvature reduction (~12–14°) and pain reduction; usually 5 million units bi-weekly × 6 doses.[1][13]

Verapamil — calcium channel blocker; some evidence for plaque softening and pain in uncontrolled series; lacks strong RCT support.[13]

Other intralesional agents — hyaluronic acid, botulinum toxin, nicardipine, corticosteroids — limited evidence; not standard of care.

Mechanical therapies​

Penile traction therapy (PTT) — devices applying longitudinal traction 2–8 hours daily.

  • Evidence for modest curvature reduction and length preservation, especially in the acute phase and as adjunct to intralesional therapy
  • Best-studied devices: RestoreX (Mayo Clinic trial data showing ~17° curvature reduction at 30 minutes 3×/day)
  • Adherence is the primary limiting factor — devices require sustained daily use[2][14]

Vacuum erection device (VED) — adjunct evidence only, typically combined with traction or injection therapy.

Extracorporeal shock wave therapy (ESWT) — effective for pain reduction in acute-phase PD but not for curvature correction. Not a primary treatment for deformity.[1][14]

Combination protocols​

Combination of CCH + traction or ESWT + intralesional agents is an area of ongoing evaluation; small studies suggest additive benefit but robust RCT data are limited.

Surgical Management​

Surgery is offered when deformity interferes with coitus despite non-surgical therapy, and disease is stable. The decision tree hinges on erectile function:

Erectile function statusSurgery of choice
Intact (including response to PDE5i, VED, ICI)Tunica plication (mild–moderate curvature) or plaque incision/excision + grafting (severe/complex)
ED unresponsive to medical therapyPenile prosthesis ± intraoperative straightening adjuncts

Tunica Plication​

The most commonly performed PD surgery (~50% of cases).[4][15] The tunica on the convex side is shortened — via plication, imbrication, or Nesbit-style wedge excision — to match the shorter concave side.

Named variants:

  • Nesbit — transverse elliptical wedge excision of the tunica on the convex side, closed primarily
  • Yachia — longitudinal incision with transverse closure on the convex side (Heineke-Mikulicz principle)
  • 16-dot (Gholami-Lue) — multiple small plication sutures, no excision; popular for its simplicity
  • Tunica albuginea plication (TAP) / Lue technique — imbrication with permanent braided sutures

Indications:

  • Curvature ≤60°
  • No hinge / hourglass / complex deformity
  • Intact erectile function (with or without PDE5i adjunct)
  • Patient acceptance of expected shortening

Outcomes:

  • Straightening success ≥90%
  • Penile shortening 1–2 cm typical; patient counseling is critical
  • Recurrence <10% long-term

Complications: shortening (universal), palpable suture knots, sensory change (usually transient), ED in a minority.[3]

Plaque Incision / Excision with Grafting​

For severe curvature (>60°), complex deformity (hinge, hourglass, biplanar), or short-penis patients where additional shortening is unacceptable.[4][15]

Technique principle: Incision or partial excision of the plaque on the concave side lengthens the short side; the resulting tunical defect is bridged with a graft.

Graft options:

GraftNotes
Acellular collagen matrix (Bard InteXen)Popular; consistent handling
Bovine pericardium (Veritas, Tutoplast)Widely used; low reactive rate
Porcine SIS (Cook Biodesign)Remodels to host tissue
Dermal graft — autologousHistorical standard; meaningful donor-site morbidity
Saphenous vein — autologousLow ED risk; donor-site consideration
Tunica vaginalis — autologousEasily harvested adjacent tissue

Outcomes:[4]

  • Straightening 80–100% across series
  • Preserves length compared with plication
  • ED risk is higher than plication (reported 10–25%) — the graft-related veno-occlusive dysfunction risk is the defining downside
  • Sensory change 5–15%

Indications:

  • Curvature >60° or complex deformity
  • Intact erectile function (or function responsive to oral medications / VED / ICI)
  • Patient willing to accept higher postoperative ED risk

Penile Prosthesis Implantation​

The operation of choice when PD coexists with ED refractory to medical therapy, or when severe deformity and ED make plication/grafting unlikely to produce a functional erection.[4][16][17]

Adjunctive straightening at implant — frequently required, and the skill set is essential:

TechniqueFrequencyCurvature correction (median)
Manual modeling (Wilson "crack" maneuver) — forceful reverse-direction bending against the inflated cylinders~75% of cases26° [IQR 20–39.5°][17]
Concurrent tunical plication over the implanted cylinders~5%40° [28–41°]
Plaque incision + grafting over the cylinders~2%55° [48–74°] — highest correction but most technically demanding

Prosthesis selection:

  • Inflatable strongly preferred — malleable prostheses do not tolerate modeling maneuvers as well
  • AMS 700 CX or Coloplast Titan OTR/Touch are routine choices
  • AMS 700 LGX is often avoided in PD because longitudinal expansion can worsen hinge deformity, though this is surgeon-dependent
  • Subcoronal approach is the preferred incision when significant tunical work (grafting) is anticipated, as it provides direct exposure of the entire shaft

See surgical approaches and preoperative evaluation in the penile implants subsection for the full operative framework.

Outcomes: >80% straightening; high patient satisfaction; no correlation between surgical complexity and infection/revision rates or satisfaction scores.[4][17]

Treatment Algorithm​

Acute phase (0–12 months)​

  1. Counsel on disease trajectory and realistic expectations
  2. Non-surgical therapy — CCH (if curvature 30–90° and stable enough for injection protocol), interferon α-2b, or traction therapy
  3. Pain-directed therapy — ESWT if pain is dominant
  4. Deferred surgery — surgery is contraindicated in active phase

Stable phase (>12–18 months, no curvature progression ≥3 months, pain resolved)​

  • Deformity interferes with coitus + intact EF → tunical plication (≤60° simple) or grafting (>60° / complex)
  • Deformity + ED refractory to medical therapy → penile prosthesis with intraoperative modeling, plication, or grafting as needed
  • Deformity not interfering with coitus → shared decision; ongoing monitoring

Shared decision-making​

The PD conversation is unusually values-laden. Patients weigh:

  • Length preservation (grafting ≥ prosthesis ≫ plication) vs. straightening reliability (prosthesis ≫ grafting ≥ plication)
  • ED risk (plication < prosthesis < grafting)
  • Recovery time and technical complexity
  • Reversibility (intralesional therapy is reversible; surgery is not)

No single answer is "correct" for all patients. The surgeon's job is to present the trade-off honestly.

Counseling Essentials​

  • Recovery to pre-disease state is unlikely. Treatments — medical and surgical — reduce deformity; they do not restore the pre-morbid penis.
  • All surgical interventions shorten the penis to some degree; plication shortens most, grafting least.
  • ED is a recognized risk of grafting and, to a lesser extent, plication. Full discussion of this is part of informed consent.
  • Psychological impact is real and underappreciated. Referral for mental-health support is part of complete care in many patients.
  • Partner involvement in counseling improves satisfaction and understanding. Bring the partner to the consent visit when possible.
  • Time is the friend of decision-making. Most non-emergent decisions can be made over weeks to months rather than days.

Special Scenarios​

Post-prostatectomy PD​

Emerging entity — PD develops or progresses in a substantial subset of men after radical prostatectomy, possibly from altered penile hemodynamics and nocturnal tumescence patterns. Concurrent post-prostatectomy ED often makes these patients candidates for primary IPP with intraoperative straightening.

Congenital curvature vs. PD​

Congenital penile curvature is present from puberty, lacks a plaque, is painless, and is managed by plication in adulthood if it interferes with coitus. Distinguishing PD from congenital curvature is a matter of history and examination.

Concurrent Dupuytren contracture​

Patients with both PD and Dupuytren contracture have the "fibrosing diathesis." There is some evidence these men respond less well to all therapies and are at higher risk of recurrence.

Pediatric / adolescent PD​

Rare; usually post-traumatic rather than idiopathic. Referral to high-volume pediatric urology centers.

See Also​

References​

1. Rosenberg JE, Ergun O, Hwang EC, et al. Non-surgical therapies for Peyronie's disease. Cochrane Database Syst Rev. 2023;7:CD012206. doi:10.1002/14651858.CD012206.pub2

2. Ziegelmann MJ, Bajic P, Levine LA. Peyronie's disease: contemporary evaluation and management. Int J Urol. 2020;27(6):504–516. doi:10.1111/iju.14230

3. Tsambarlis P, Levine LA. Nonsurgical management of Peyronie's disease. Nat Rev Urol. 2019;16(3):172–186. doi:10.1038/s41585-018-0117-7

4. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's disease: AUA guideline. J Urol. 2015;194(3):745–753. doi:10.1016/j.juro.2015.05.098

5. Salonia A, Capogrosso P, Boeri L, et al. European Association of Urology guidelines on male sexual and reproductive health: 2025 update on male hypogonadism, erectile dysfunction, premature ejaculation, and Peyronie's disease. Eur Urol. 2025;88(1):76–102. doi:10.1016/j.eururo.2025.04.010

6. Chierigo F, Fallara G, Tozzi M, et al. Guideline of guidelines: Peyronie's disease. BJU Int. 2026;137(5):770–782. doi:10.1111/bju.70201

7. Patel DP, Christensen MB, Hotaling JM, Pastuszak AW. A review of inflammation and fibrosis: implications for the pathogenesis of Peyronie's disease. World J Urol. 2020;38(2):253–261. doi:10.1007/s00345-019-02815-6

8. Şahin A, Babayev H, Cirigliano L, et al. Unveiling the molecular hallmarks of Peyronie's disease: a comprehensive narrative review. Int J Impot Res. 2024;36(8):801–808. doi:10.1038/s41443-024-00845-2

9. Swislocki ALM, Eisenberg ML. Peyronie disease as a marker of inflammation — is there hope on the horizon? Am J Med. 2021;134(10):1218–1223. doi:10.1016/j.amjmed.2021.06.015

10. Chung E, Gillman M, Tuckey J, La Bianca S, Love C. A clinical pathway for the management of Peyronie's disease: integrating clinical guidelines from the International Society of Sexual Medicine, American Urological Association and European Urological Association. BJU Int. 2020;126 Suppl 1:12–17. doi:10.1111/bju.15057

11. Russo GI, Milenkovic U, Hellstrom W, et al. Clinical efficacy of injection and mechanical therapy for Peyronie's disease: a systematic review of the literature. Eur Urol. 2018;74(6):767–781. doi:10.1016/j.eururo.2018.07.005

12. Minore A, Cacciatore L, Presicce F, et al. Intralesional and topical treatments for Peyronie's disease: a narrative review of current knowledge. Asian J Androl. 2025;27(2):156–165. doi:10.4103/aja202460

13. Hayat S, Brunckhorst O, Alnajjar HM, et al. A systematic review of non-surgical management in Peyronie's disease. Int J Impot Res. 2023;35(6):523–532. doi:10.1038/s41443-022-00633-w

14. Levine LA, Rybak J. Traction therapy for men with shortened penis prior to penile prosthesis implantation: a pilot study. J Sex Med. 2011;8(7):2112–7. doi:10.1111/j.1743-6109.2011.02262.x

15. Levine LA, Lenting EL. A surgical algorithm for the treatment of Peyronie's disease. J Urol. 1997;158(6):2149–52. doi:10.1016/s0022-5347(01)68184-9

16. Chung E, Blecher G. Perspective: residual penile curvature correction during penile prosthesis implantation by plication in Peyronie's patients. Int J Impot Res. 2023;35(7):643–646. doi:10.1038/s41443-023-00774-6

17. Hammad MAM, Barham DW, Simhan J, et al. A multicenter evaluation of penile curvature correction in men with Peyronie's disease undergoing inflatable penile prosthesis placement. J Sex Med. 2025;22(2):349–355. doi:10.1093/jsxmed/qdae192