Scott Webb (Host): Peyronie's disease is not a common condition for men. But for those who suffer from it, it can be painful. There are some treatment options. And joining me today to tell us about Peyronie's disease and the symptoms and treatment options is Dr. Ryan Griggs. He's a urologist with Salinas Valley Health Urology.

Host: This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's so nice to have your time today. We're going to talk about Peyronie's disease and who experiences it, what do they experience, when they have it, how you can help them, and all that good stuff. So, just as a baseline here as we get rolling, what is Peyronie's disease?

Dr. Ryan Griggs: Peyronie's disease is a relatively uncommon disease affecting males and it's most likely underreported. But it's also abbreviated PD similarly to erectile dysfunction is abbreviated as ED. The American Urological Association panel, who's the governing body of treating this condition, defines it as an acquired penile abnormality characterized by scarring of the lining of the tubes of the penis that become erect when you have an erection. And it can be associated with pain, penile deformity, which is most likely a curvature and, most commonly, indentation or an hourglass formation of the penis and penile shortening. All bad words, right?

Host: Yeah.

Dr. Ryan Griggs: Erectile dysfunction and/or psychological stress. It's most commonly caused by trauma that you don't necessarily remember, and they dub it as microvascular trauma to the shaft. It's usually associated with buckling of a very rigid penis or penetrative sex with a semi-erect penis during sex is a most common inciting event. But many patients, as I said, don't remember a specific event. It just tends to kind of progress over time. And I think in regards to associated conditions, it's usually associated with aging, diabetes, erectile dysfunction, psychological stress, after getting your prostate removed, low testosterone called hypogonadism or other collagen disorders.

Host: Yeah. There's a whole bunch to unpack there. But let's talk about the pain associated and whether it's a painful condition, especially during intercourse.

Dr. Ryan Griggs: The best answer is it can be painful. There's actually a congenital condition called congenital penile curvature. And these patients have a condition where the tubes of the penis grow too much on the top, but not enough on the bottom. And these patients have curvature of their penis their entire life. It's usually mild and they're able to have penetrative sex and it's not uncomfortable for the patient or the partner and they just kind of know about it because their partner hasn't seen a bent member before. In the actual pathologic condition, because of that scarring and curvature that may occur, it may be for the patient just painful to have an erection. But that being said, it can also be painful during intercourse, especially for the partner.

Host: Let's talk about the treatment options then. Are we talking about medication, surgery? I assume you've performed some surgeries there at Salinas Valley Health, so maybe you can take us through this. What's the course of treatment when a guy comes in and actually, you know, kind of speaks up about this?

Dr. Ryan Griggs: One of the things we need to tease out is whether they're in a certain phase of the condition. And there's two phases. There's active and stable or chronic phase. And so, chronic phase would be characterized by pain with erections or pain in the flacid state with progressive curvature, usually lasting about six to 12 months. There's two kind of schools of thought on that. There's people who like to treat in the acute phase, and I'll get to that in a second, in order to prevent the curvature from getting worse. And then, there's a larger cohort that likes to treat when the disease has already manifested its sequela.

So then, stable is usually defined by a clinically stable or unchanged state for at least three months, meaning curvature and lack of pain. So in regards to that acute treatment, as I said, medications can be used in the acute phase and there's a lot of research kind of going on between that, because a lot of patients don't want to wait to treat the condition. They kind of want to get ahead of the horse. So, palliation is what my governing body suggests for erectile pain and PDE5 inhibitors, which are your Viagra, Cialis, Levitra, Stendra, et cetera, to help with erectile dysfunction. And that's supported with anti-inflammatories, so your Mobic or your Motrin, Naproxen, et cetera.

But then, there's a lot of research with some of the more prominent Peyronie's physicians out there, especially in Chicago, where they're using a trimodal oral therapy consisting of pentoxifylline, L-arginine and PDE5 inhibitors. And these have only been shown to be effective in rat studies, and they have suggested an antifibrotic or anti-scarring effect with an elevated transmitter called nitric oxide in the tissue. And like I said, it hasn't been shown in humans yet. But furthermore, our society doesn't really endorse offering these agents. But some patients are desperate for treatment and they're relatively well tolerated. So, there's definitely a large proportion that use it, but a larger portion that do not.

A different medication is an intralesional injection called Xiaflex. It's a enzyme that breaks down collagen, and it's the conversion of one type of collagen to a bad type of collagen. It breaks down the bad type of collagen that causes scarring, and you can do this if the curvature is greater than 30 degrees and can be offered off-label according only to studies looking back in time. But basically, we need further studies with more people and going forward in time to really solidify this recommendation. Then once you hit the chronic phase, then you have intralesional injection with Xiaflex, as I said, instead of using it in the acute phase, using it in the chronic phase. That's done with two injections into the penis separated by one to three days. Notably, there's no sexual activity of any kind between injections or in the four weeks after. One to three days after the second injection, we perform modeling in the office and no, that's not taking pictures. But we basically do stretching and bending maneuvers of the penis to try and break up that plaque or scar tissue. And you can do up to four cycles and the cycles are separated by four to six weeks.

There's another type of intralesional therapy called verapamil. And my previous training director used to call this the jackhammer technique because you basically used this calcium channel blocker called verapamil, and it's been shown to stop cellular scarring and growth and reduce scar formation by inducing good collagen enzymes. And the reason why I call this the jackhammer technique like my previous trainer did, is because you inject the penis, but while you have the needle in the penis, you make an up and down motion, kind of putting perforations into the plaque to make it softer, so you can distribute the medication.

Notable things about these two medications, penile aching, bruising, hypersensitivity or allergy to the agent, brief numbness can occur, but it stabilizes the curve at a mean of 15 to 30 degrees. If you do the injectable medication plus traction, the mean curvature correction is almost 27 degrees. And then, there's traction. And traction is not medication. It's not invasive. It can just be a little bit uncomfortable.

There's two different devices recommended. There's the PeniMaster Pro, appropriately named, and you have to do that three hours at least, up to ideally eight hours a day, which is a significant time commitment obviously with a 30-minute break every three hours. Then, there's the RestoreX device, which is the newer device on the market. It was developed by a Mayo Clinic, and this looks like a penile ring and stretcher that you need two treatments, 30 minutes each treatment a day for 12 weeks in order to see some type of improvement.

Host: So, is surgery ever an option? is there a point where surgery is indicated?

Dr. Ryan Griggs: Yeah. Surgery is only offered in the chronic or stable phase.

Host: Okay. And so when we think about recovery, and I know there's a gamut here of again, you know, how it's presenting, how long it's been going on, the severity and so forth, but what's the recovery generally, like for a patient? How long are we talking about? A few weeks before they can have intercourse? Are we talking months, years? What's the timeline?

Dr. Ryan Griggs: A month and a half is the mean. We try to have people stay away from sexual activity for six weeks to let the surgical site heal. And what I would say is before we approach surgery is we try to glean from the patient do they want a functional erection or do they want an arrow straight correction. And that kind of guides us to what we're going to do. Are we looking at doing just traction for them, an intralesional therapy to get them to a functional state? Are we doing a more radical procedure like plication, which is a shortening procedure traditionally? Although most patients don't have measurable shortening. And then, there's plaque partial incision or excision and grafting, which is a highly arduous procedure. It can last two to three hours. But the recovery is the same for any surgery, is six weeks.

So with plication, it's a circumcising incision traditionally. However, most newer urologists will do a local incision on the opposite side of the curvature. So, for example, if the penis is bending up, you make an incision on the bottom of the penis. And then, you put permanent stitches in and those stitches are then tied together to shorten the long side. Because if you think of a banana, if you were to measure the length on the bottom end of the curve, it's a longer distance than the top of the curve. So, the idea is to shorten the longer curve to make it straight. You do a simple penile gauze wrap 21 hours a day, three hours off, so that's when you're going to be showering, et cetera, for six weeks. And you do an ointment application to the incision for one to two weeks to help it heal.

For plaque partial excision grafting, this does require a circumcision. So, patients who are uncircumcised, it's important to note they're circumcised after the procedure is done. So, that's an important thing to note because you have to de-glove the penis all the way. And if you don't circumcise the patient and they're uncircumcised, the swelling of the penis afterwards can cause a surgical condition called paraphimosis, where the foreskin gets caught behind the head of the penis, causing more swelling, pain and the inability to pull it forward. And that can cause decreased vascular flow to the head of the penis, and I assure you nobody likes that.

Host: Yeah, no. Well, of everything we've discussed here today and things that I definitely don't want to ever experience, I'm going to put that one pretty close to the top, if not at the top of the list.

Dr. Ryan Griggs: No doubt, no doubt. And so, that one you do a dressing for three days and then you can shower. There's no submersion. You get antibiotics for five weeks. one week postop, you start an erectogenic medication called Cialis Daily of five milligrams and a pill of nitric oxide to increase blood flow for one month. And this is done at night and you followup in two weeks. And then after the two weeks, you're cleared to do daily massage and stretching exercises. And then at four to six weeks, we ask the partner to do this.

The traction, which is pulling and bending the penis begins three to five weeks post-op, two hours a day for three months. And at six weeks, sex begins if they're healed. But you have to use lots of lube, and only if the wounds are all healed. People with poor erections get an inflatable penile prosthesis, which is a mechanical device that's inserted. And sometimes just putting the penile prosthesis in straightens the curvature, depending on how severe it is and it corrects a mean of 20 to 30 degrees. And sometimes you need adjunctive maneuvers and there's various ways to do that. But long story short is sometimes you have to do other things besides just putting the penile prosthesis.

Host: Yeah, sometimes it works and sometimes more is needed. Any final thoughts and takeaways? I'm sure one of them is to just encourage guys not to live with this, that they don't have to suffer. But what else?

Dr. Ryan Griggs: The number one thing is that if you do seek treatment, only speak with specially trained urologists like myself who treat the condition regularly, and that's actually supported by the guidelines of American Urologic Association. I think that's a very important factor because there's a lot of men's health clinics popping up around the nation, particularly in urban areas that are non-urologists. And some people are offering shockwave therapy and all of these different modalities to treat Peyronie's disease that are not supported.

Host: That's great advice from an expert. And it's really important that we seek out the advice, the, recommendations, the treatment from an expert like yourself. So, thanks so much for your time today. You stay well.

Dr. Ryan Griggs: It's my pleasure. Take care, Scott.

Host: And to make an appointment, call Salinas Valley Health Urology at 831-422-4500. That's 831-422-4500. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor or family member, and subscribe, rate, and review this podcast and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.