Peyronie's Disease in Men Over 40: Why the Curve Appears, the Testosterone Link, and What the Trials Show

Peyronie's disease is scar tissue, called a plaque, that forms in the lining of the erectile chambers and bends or shortens the penis during erections. Surveys put it at roughly 3 to 9 percent of adult men, with rates climbing after 40. Most men go through a painful acute phase of 6 to 18 months before the curve stabilizes, and the treatments with the best trial data are injections, traction and, for severe or stable cases, surgery.

Peyronie's disease is a buildup of scar tissue inside the penis that causes a bend, an indentation or a loss of length during erections, and it shows up most often in men between 40 and 70. The scar, called a plaque, forms in the tunica albuginea, the tough sheath that wraps the two erectile chambers. Because that patch of scar tissue does not stretch the way healthy tissue does, the penis bends toward the plaque when it fills with blood.

Many men with a new curve assume it is rare, embarrassing and permanent. None of those three is quite true. Peyronie's disease is common enough that most urologists see several new cases a week, it follows a fairly predictable course, and the first year is when decisions carry the most weight. The research also has a few surprises, including a strong overlap with low testosterone and a list of popular supplements that clinical guidelines now advise against.

Peyronie's disease is thought to start with small, often unnoticed injuries to the penis during sex or other activity, followed by abnormal healing that lays down too much dense collagen. Most men cannot recall a specific injury. Researchers believe repeated microtrauma during erections that bend under pressure lets blood leak into the layers of the tunica albuginea, which sets off an inflammatory response driven by the signaling molecule TGF-beta 1. In most men that response resolves cleanly. In men with Peyronie's disease it overshoots and leaves a firm, inelastic scar.

Several conditions raise the odds of Peyronie's disease, and most of them become more common after 40. Erectile dysfunction is the strongest association, partly because softer erections buckle more easily during sex. Diabetes, smoking, high blood pressure and Dupuytren's contracture, a similar scarring condition in the palm of the hand, all show up more often in men with the disease. Radical prostatectomy is another trigger: Tal and colleagues reported in the Journal of Sexual Medicine in 2010 that 15.9 percent of men developed Peyronie's disease after prostate removal.

Peyronie's disease affects roughly 3 to 9 percent of adult men in most surveys, and the rate rises steadily with age. The best-known population survey, by Schwarzer and colleagues in Cologne, mailed questionnaires to 8,000 men and reported a prevalence of 3.2 percent among the 4,432 who answered, with the highest rates in men over 60. Studies that examine men in a clinic rather than rely on questionnaires usually find more cases, because embarrassment keeps many men from reporting a curve at all.

The age pattern above comes from the Schwarzer survey and should be read as a floor rather than a ceiling. A 2016 systematic review by Stuntz and colleagues in the International Journal of Impotence Research found that estimates vary widely with study method, and that probable cases, where a man reports curvature or a lump but has not been formally diagnosed, run several times higher than confirmed cases.

Peyronie's disease rarely goes away completely on its own, but the pain almost always does, and a minority of men see the curve improve without treatment. John Mulhall and colleagues followed 246 untreated men for a mean of about 18 months and reported in the Journal of Urology in 2006 that 12 percent improved, 40 percent stayed the same and 48 percent got worse. Pain with erections, by contrast, resolved in most men within the first 12 to 18 months.

Urologists split Peyronie's disease into two phases because the right approach differs between them. The acute or active phase is when the plaque is still forming: erections may hurt, the curve may be changing month to month, and the lump may feel tender. The chronic or stable phase begins once pain has gone and the curve has stayed the same for at least 3 months. Surgery is generally held back until the chronic phase, because operating on a curve that is still moving risks having to operate again.

Peyronie's disease and low testosterone overlap far more than chance would predict. Jaime Moreno and Abraham Morgentaler measured testosterone in 121 men with Peyronie's disease and reported in the Journal of Sexual Medicine in 2009 that 74 percent had low total or free testosterone. Men with lower testosterone also tended to have more severe curvature.

A plausible reason for the testosterone link is tissue quality. Androgens help maintain the smooth muscle and connective tissue inside the penis, and animal studies show that castration leads to more collagen and less elastic fiber in the erectile tissue. Low testosterone also weakens erections, and partial erections bend more easily during sex, which may raise the risk of the microtrauma thought to start the disease. None of this proves that low testosterone causes Peyronie's disease, and no randomized trial has shown that testosterone therapy straightens an existing curve.

Collagenase clostridium histolyticum, sold as Xiaflex, is the only drug approved by the FDA for Peyronie's disease, and it reduced curvature by about a third in the two trials behind that approval. The IMPRESS I and II trials, published by Martin Gelbard and colleagues in the Journal of Urology in 2013, randomized 832 men with stable curves of 30 to 90 degrees. Men who received collagenase had a mean curve reduction of 34 percent, about 17 degrees, compared with 18 percent, about 9 degrees, in men given placebo.

Collagenase treatment involves up to four cycles, each made of two injections into the plaque a few days apart followed by gentle stretching called modeling, with cycles about 6 weeks apart. Bruising and swelling are common. The most serious risk is corporal rupture, a penile fracture, which occurred in under 1 percent of men in the trials, and men are told to avoid sex for 2 to 4 weeks after each cycle. The drug is less effective for hourglass deformities and heavily calcified plaques.

Penile traction therapy, which uses a device to apply steady stretching force, has the strongest evidence of any non-drug option, as long as men wear it long enough. In the RestoreX trial, published by Landon Trost's group at the Mayo Clinic in the Journal of Urology in 2019, 110 men were randomized to traction or no treatment for 3 months. Men who used the device for 30 to 90 minutes a day improved their curve by about 38 percent, roughly 13 degrees, and gained about 1.5 centimeters of length compared with controls.

Older traction devices required 3 to 8 hours of daily wear, and adherence was the main reason they disappointed. Traction is also often combined with collagenase injections to help preserve length, since length loss is one of the most distressing parts of the disease for many men. Vacuum erection devices are sometimes used in the same way, although the evidence behind them is thinner.

The American Urological Association guideline on Peyronie's disease advises clinicians not to use oral vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or the combination of vitamin E with L-carnitine, because trials did not show meaningful benefit. That list covers several of the most heavily marketed home remedies. Pentoxifylline and potassium para-aminobenzoate, sold as Potaba, have weak or mixed evidence. Low-intensity shockwave therapy may ease pain but has not been shown to straighten the curve.

Surgery is usually considered when Peyronie's disease has been stable for at least 3 to 6 months and the curve or deformity makes sex difficult or impossible. Plication, which shortens the longer side of the penis with stitches, is the simplest option and suits men with good erections and curves under roughly 60 degrees, at the cost of some length. Incision or partial removal of the plaque with a graft suits severe curves and hourglass shapes but carries a higher risk of new erectile dysfunction.

Men with Peyronie's disease and erectile dysfunction that does not respond to tablets such as tadalafil are often best served by a penile prosthesis, sometimes with modeling or a small graft at the same operation. Choosing among the three surgical options depends far more on erection quality than on the angle of the curve, which is why urologists often perform a penile Doppler ultrasound with an injected erection before recommending surgery.

Peyronie's disease takes a heavier psychological toll than most men expect. Christian Nelson and colleagues at Memorial Sloan Kettering reported in the Journal of Sexual Medicine in 2008 that close to half of men with Peyronie's disease had clinically meaningful depressive symptoms, and many reported relationship strain. Talking with a partner early, and seeing a urologist rather than waiting, tends to reduce the anxiety that builds when men try to manage the problem alone.

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