Peyronie's disease, characterised by fibrous plaques in the penis, affects 3–9% of men and frequently causes erectile dysfunction (ED). Research shows that 20–54% of men with Peyronie's disease experience ED, reflecting the condition's impact on penile structure, blood flow, and psychological wellbeing. The plaques reduce tissue elasticity, disrupt the veno-occlusive mechanism, and may cause venous leak, impairing the ability to achieve or maintain erections. Anxiety, relationship strain, and reduced self-esteem further compound erectile difficulties. Understanding this multifactorial relationship is essential for effective management, as treatment must address both structural abnormalities and erectile function to restore sexual health and quality of life.

Understanding Peyronie's Disease and Erectile Dysfunction

Peyronie's disease is a connective tissue disorder characterised by the development of fibrous scar tissue (plaques) within the tunica albuginea of the penis. This condition affects approximately 3–9% of men, though prevalence may be higher due to underreporting. The plaques cause penile curvature, pain during erection, and in many cases, erectile dysfunction (ED). Whilst some men experience only mild curvature without functional impairment, others develop significant deformity that interferes with sexual intercourse. The natural history varies—some cases stabilise or occasionally improve, but many persist without treatment.

Erectile dysfunction refers to the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance. ED can arise from vascular, neurological, hormonal, or psychological causes. When associated with Peyronie's disease, the relationship is often multifactorial, involving both physical changes to penile structure and psychological distress related to the condition.

Research indicates that between 20% and 54% of men with Peyronie's disease experience some degree of erectile dysfunction. This wide range reflects variations in disease severity, patient age, and the presence of other risk factors such as diabetes or cardiovascular disease. The connection between Peyronie's disease and ED is well established in clinical literature, with the plaques directly affecting the mechanical and vascular function of the penis. Importantly, ED may also signal underlying cardiovascular disease, so assessment should include optimisation of cardiovascular risk factors. Understanding this relationship is essential for appropriate management, as treatment strategies often need to address both the structural abnormality and the erectile difficulties simultaneously to restore sexual function and quality of life.

How Peyronie's Disease Affects Erectile Function

The mechanism by which Peyronie's disease causes erectile dysfunction involves several interconnected pathophysiological processes. The fibrous plaques that form in the tunica albuginea are composed of collagen and fibrin, creating areas of reduced elasticity. During erection, when the corpora cavernosa fill with blood, these inelastic regions prevent uniform expansion, resulting in penile curvature and potentially compromising the veno-occlusive mechanism essential for maintaining rigidity.

Vascular compromise represents a key factor in Peyronie's-related ED. The plaques create areas of tunical inelasticity that disrupt the normal veno-occlusive function, leading to venous leak—a condition where blood drains from the penis too quickly to sustain an erection. Additionally, the fibrotic process may extend beyond the visible plaque, affecting the smooth muscle and endothelial function of the corpora cavernosa. This can impair arterial inflow and reduce the penis's capacity to trap blood effectively.

Penile shortening is another consequence of Peyronie's disease that contributes to erectile difficulties. As scar tissue contracts, it can reduce both erect and flaccid penile length, which may affect confidence and sexual function. Studies using penile duplex ultrasonography have demonstrated that men with Peyronie's disease often show reduced peak systolic velocity and increased end-diastolic velocity, indicating both arterial insufficiency and venous leak. The severity of these haemodynamic changes often correlates with plaque calcification and degree of curvature.

The acute inflammatory phase of Peyronie's disease, which typically lasts 6–18 months (though may extend up to 24 months), may be associated with painful erections that discourage sexual activity. Even after stabilisation, the structural changes persist, and the chronic phase is characterised by established curvature and ongoing erectile difficulties. The severity of ED often correlates with plaque size, degree of curvature, and the extent of calcification within the plaque.

Physical and Psychological Factors in ED with Peyronie's

Whilst the physical mechanisms of Peyronie's-related erectile dysfunction are significant, psychological factors play an equally important role in the overall clinical picture. Men with Peyronie's disease frequently experience anxiety, depression, and reduced self-esteem related to changes in penile appearance and sexual function. Research indicates that up to 81% of men with Peyronie's disease report psychological distress, which can independently contribute to or exacerbate erectile difficulties.

Performance anxiety is particularly common, as men may worry about their ability to achieve penetration due to curvature, or fear pain during intercourse. This anxiety triggers a stress response that increases sympathetic nervous system activity, which is counterproductive to the parasympathetic dominance required for erection. The resulting cycle of anxiety and erectile failure can persist even if the physical aspects of Peyronie's disease improve with treatment.

Relationship difficulties often emerge as couples navigate the challenges of Peyronie's disease together. Communication problems, reduced intimacy, and partner distress are frequently reported. Some men avoid sexual activity altogether to prevent embarrassment or discomfort, leading to further relationship strain and reinforcing erectile difficulties. Partner involvement in treatment discussions and psychological support can be beneficial for both parties.

The interaction between physical and psychological factors creates a complex clinical scenario. For instance, a man with moderate curvature and mild vascular compromise might develop severe ED primarily due to psychological factors, whilst another with similar physical findings but better psychological resilience might maintain adequate erectile function. Assessment must therefore consider both domains. Validated questionnaires such as the International Index of Erectile Function (IIEF) and measures of psychological wellbeing help clinicians understand the relative contribution of each factor and tailor treatment accordingly. In the UK, NHS sexual health services and psychosexual therapy can provide valuable support for the psychological aspects of the condition.

Treatment Options for ED Caused by Peyronie's Disease

Management of erectile dysfunction associated with Peyronie's disease requires a comprehensive, individualised approach that addresses both the underlying penile deformity and the erectile difficulties. Treatment selection depends on disease phase (acute versus chronic), severity of curvature, degree of ED, and patient preferences.

Oral phosphodiesterase type 5 (PDE5) inhibitors—including sildenafil, tadalafil, and vardenafil—represent first-line pharmacological treatment for ED in Peyronie's disease. These medications enhance nitric oxide-mediated smooth muscle relaxation in the corpora cavernosa, improving arterial inflow and erectile rigidity. Response rates vary, with better outcomes in men whose ED has a significant psychological component or mild vascular compromise. Some preliminary research suggests that daily low-dose PDE5 inhibitors might have anti-fibrotic effects, though this remains investigational and is not a licensed indication. PDE5 inhibitors are contraindicated in patients taking nitrate medications and require careful consideration of drug interactions; patients should consult the medication's patient information leaflet or SmPC for full safety information.

Penile traction therapy involves the application of a stretching force to the penis for several hours daily. Evidence suggests this may help reduce curvature, preserve or increase penile length, and potentially improve erectile function. Vacuum erection devices (VEDs) offer another non-invasive option that may help maintain penile length and improve erectile function. Regular use during the acute phase might help preserve length, whilst in the chronic phase, VEDs can assist with achieving erections adequate for intercourse. Some men use VEDs in combination with constriction rings to enhance rigidity.

Intralesional injection therapies are sometimes used to target the plaque directly. It should be noted that collagenase clostridium histolyticum, while used in some countries for Peyronie's disease, is not currently licensed or marketed for this indication in the UK. Other intralesional treatments such as verapamil and interferon alpha-2b are used off-label in some specialist centres, though evidence for their efficacy is mixed and they are not routinely recommended in UK practice.

Intracavernosal injections of alprostadil may be considered for ED if PDE5 inhibitors are ineffective or contraindicated, though patients should be counselled about potential risks in the context of Peyronie's disease.

Surgical intervention is reserved for men with stable disease (when deformity has been stable for at least 3 months and typically >12 months after onset) and severe curvature or ED unresponsive to conservative measures. Options include:

• Plication procedures: Shortening the longer side of the penis to correct curvature, preserving erectile tissue

• Plaque incision or excision with grafting: Lengthening the shorter side, suitable for more severe deformity

• Penile prosthesis implantation: Definitive treatment for men with both significant curvature and severe ED refractory to other therapies

British Association of Urological Surgeons (BAUS) and European Association of Urology (EAU) guidelines emphasise that surgical decisions should involve detailed discussion of risks, benefits, and realistic expectations. Psychological support and psychosexual counselling should be offered alongside physical treatments, as addressing anxiety, depression, and relationship issues significantly improves overall outcomes.

Patients should report any suspected side effects from medications to the MHRA Yellow Card scheme.

When to Seek Medical Help for Peyronie's and Erectile Problems

Early consultation with a GP or urologist is advisable for any man experiencing penile curvature, pain during erection, or erectile difficulties. Whilst some degree of penile curvature is normal, progressive or sudden changes warrant medical assessment. Early assessment helps manage pain and sexual function, though the natural course of Peyronie's disease varies between individuals.

Specific triggers for seeking medical attention include:

• Noticeable penile curvature or deformity developing over weeks to months

• Painful erections that interfere with sexual activity

• Palpable lumps or hard areas in the penile shaft

• Difficulty achieving or maintaining erections sufficient for intercourse

• Penile shortening or changes in penile shape

• Significant anxiety or distress related to sexual function

• Relationship difficulties arising from sexual problems

Emergency assessment is required for:

• Sudden onset of severe penile pain with a 'popping' sensation during sexual activity, immediate detumescence and penile swelling (possible penile fracture)

• Priapism (prolonged, painful erection lasting more than four hours)

• Inability to urinate

During the initial consultation, clinicians will typically take a detailed sexual and medical history, perform a physical examination to assess plaque location and penile curvature, and may request photographs of the erect penis (taken at home) to document deformity. Assessment of cardiovascular risk factors is important, including blood pressure, lipids, HbA1c/glucose, and smoking status, as ED may signal underlying cardiovascular disease. Testosterone testing may be arranged for men with symptoms or signs of hypogonadism.

Referral to urology services is appropriate for men with functional impairment, significant distress, progressive deformity, uncertain diagnosis, or those considering interventional treatments. Specialist assessment may include penile duplex ultrasonography to evaluate blood flow and identify vascular causes of ED. Psychological support services should be offered to all men experiencing distress related to Peyronie's disease and erectile dysfunction, as integrated care addressing both physical and psychological aspects yields the best outcomes for sexual function and quality of life.

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