Penile Prosthesis and Severe Erectile Dysfunction: A Definitive Solution for Complex Peyronie’s Disease in Portugal

In cases of Peyronie’s disease associated with severe erectile dysfunction, placement of a penile prosthesis may constitute a valid surgical option, always dependent on specialized urological evaluation.

In more advanced stages, Peyronie’s disease may result in significant penile deformity and may be associated with erectile dysfunction of organic cause. In these clinical contexts, conservative approaches are often insufficient, and reconstructive surgery with placement of a penile prosthesis may constitute an appropriate therapeutic option to treat penile deformity and associated erectile dysfunction, according to the individual clinical evaluation.

In cases in which fibrosis is stable, with a deformity that impairs penetration or when it causes or worsens poor vascularization of the corpora cavernosa, leading to erectile dysfunction, simple penile straightening may not be sufficient to restore functional conditions adequate for sexual activity.

In these cases, penile reconstruction with anatomical preparation for placement of a penile prosthesis constitutes an approach described in the literature and used in selected clinical contexts.

Complex Peyronie’s disease: when the condition goes beyond the initial stage

Peyronie’s disease may evolve differently over time in each patient. In some men, structural changes in the penis become more complex and may also impair erectile function.

What distinguishes complex Peyronie’s disease from simple forms

Peyronie’s disease does not always present in the same way. There are simple forms and complex forms, and this distinction is important because each one implies different levels of impact on penile anatomy and function.

In simpler forms, the disease usually presents with curvature up to 30°, generally caused by a localized fibrous plaque, without extensive structural changes. In these cases, penile length remains relatively preserved and the patient may still maintain sexual activity, depending on the functional impact of the curvature and the presence or absence of associated erectile dysfunction. In addition, clinical follow-up and conservative treatments may be indicated.

In complex Peyronie’s disease, however, fibrosis tends to cause more relevant structural changes, with greater extent and involvement of deeper tissue layers. As a consequence, a more pronounced penile curvature may arise, capable of also altering penile length and stability during erection.

Among the most frequent characteristics of complex penile deformity are:

Extensive or multiple plaques: Fibrosis is not limited to a single point and may be distributed along the membrane that covers the corpora cavernosa.
Deep fibrosis: in some cases, the fibrotic process reaches deeper layers of erectile tissue, and not only the tunica albuginea.
Multiplanar deformity: the deformity occurs in more than one direction, such as lateral and ventral curvature at the same time.
Calcified plaques: the calcification process makes plaques more rigid and less susceptible to conservative treatment.
“Hourglass” deformity: localized thinning of the penis occurs in a given area, caused by fibrotic retraction.
Penile shortening: as the penis curves due to retraction of fibrous plaques, there is a reduction in penile length during erection.

It is important to emphasize that not all patients develop these changes.

Relationship between advanced Peyronie’s disease and severe erectile dysfunction

Peyronie’s disease and erectile dysfunction are often linked. However, many patients do not realize that difficulty obtaining or maintaining an erection may be a direct consequence of the acquired penile curvature itself, and not necessarily a separate condition.

When the distension capacity of the tunica albuginea decreases, the veno-occlusive mechanism responsible for keeping blood inside the corpora cavernosa during erection stops functioning effectively, facilitating early blood outflow through the venous system. As a consequence, erection rigidity is impaired.

In more advanced cases, fibrosis may affect the corpora cavernosa, which significantly reduces the ability to obtain or maintain an erection.

Conservative approaches in advanced Peyronie’s disease: indications and limitations

Peyronie’s disease may be approached through different therapeutic strategies, depending on the stage of the disease, the severity of the deformity, and the impact on erectile function.

Among these options are non-surgical treatments, which may be indicated in certain contexts.

Non-surgical treatments: at what stage are they considered?

In the initial phase of Peyronie’s disease, or in selected situations of stable disease without severe erectile dysfunction, non-surgical treatments may be considered as a first therapeutic approach.

These clinical and complementary alternatives aim to limit disease progression and contribute to curvature stabilization, ideally to a degree that does not compromise sexual function. Non-surgical treatments may also contribute, in some cases, to supporting erectile function.

Among the main non-surgical approaches used in clinical practice are:

Oral medication: drugs such as sildenafil and tadalafil may be considered in certain cases to support erectile function.
Intralesional injections: direct application of medications into the fibrous plaque, such as alprostadil, interferon, and verapamil.
Penile traction: devices that apply progressive mechanical stretching and may be used as a complementary therapy in selected cases.
Penile physiotherapy: penile tissue rehabilitation techniques, generally used as complementary therapy.
Vacuum pump: a device that stimulates blood flow to the penis and may be used in rehabilitation protocols defined by the urologist.
Shock waves: used mainly for pain relief in the inflammatory phase of Peyronie’s disease.

However, it is important to note that none of these approaches aims to reverse established penile curvature. In addition, in stable forms of Peyronie’s disease associated with significant erectile dysfunction, non-surgical treatments tend to have limited benefit.

According to the European Association of Urology (EAU) guidelines, when erectile function is impaired and does not respond to pharmacological therapy, penile prosthesis becomes one of the main options for treating deformity and providing adequate penile rigidity in selected cases.

Clinical criteria leading to surgical indication

The decision to move forward with surgery is not a choice the patient should make on his own initiative, nor does it depend on a single isolated factor.

Surgical indication requires an individualized clinical evaluation carried out by the urologist, who analyzes disease evolution, functional impact on sexual activity, and the response to previously performed non-surgical treatments.

In general, urological surgical intervention is considered when structural penile changes begin to significantly compromise sexual function, or when non-surgical therapeutic approaches do not produce sufficient benefit.

In addition, before considering any surgical procedure, it is important that Peyronie’s disease be in a stable phase, without progression of curvature or deformity for an approximate period of three to six months.

Penile prosthesis as a surgical strategy in complex Peyronie’s disease

The association of Peyronie’s disease with erectile dysfunction may require a surgical approach that simultaneously treats curvature and erectile function. In these situations, surgery may combine penile reconstruction techniques with placement of a penile prosthesis.

Curvature correction associated with penile prosthesis placement

In cases of complex Peyronie’s disease, the surgical procedure may include penile deformity correction techniques associated with placement of a penile prosthesis, when there is relevant erectile dysfunction. This approach seeks to restore penile alignment and provide adequate mechanical conditions for sexual activity when there is relevant erectile dysfunction.

For this purpose, a penile reconstruction technique involving small incisions in the tunica albuginea, based on geometric principles, may be used. These incisions allow remodeling of areas affected by fibrosis and promote tissue expansion, optimizing penile dimensions for prosthesis placement.

This reconstructive step is particularly important because simple placement of the prosthesis in a penis with significant fibrosis may not be sufficient to correct the deformity or provide adequate functional penile stability. Even so, the chosen surgical technique may vary according to the characteristics of each case.

The surgeon’s experience is a relevant factor in this type of procedure, since reconstructive penile surgery involves intraoperative decisions that may influence functional outcomes.

What is a penile prosthesis and how does it fit into treatment?

A penile prosthesis is a device surgically implanted inside the corpora cavernosa of the penis. This implant provides rigidity when the erectile mechanism is compromised, potentially providing adequate mechanical conditions for sexual activity.

There are two main types of penile prostheses used in clinical practice:

Inflatable prosthesis: composed of two cylinders implanted in the corpora cavernosa, a small pump placed in the scrotum, and a saline solution reservoir. When the pump is activated, fluid is transferred to the cylinders, producing an erection. After sexual intercourse, the system can be deactivated, allowing the penis to return to a flaccid state.
Malleable prosthesis: flexible cylinders make up the prosthesis, keeping the penis in a semi-rigid position. The patient may position the device manually downward, upward, or laterally, as needed.

In the context of complex Peyronie’s disease, the penile prosthesis aims to provide sufficient penile rigidity when erectile function is compromised, allowing recovery of the structural conditions necessary for sexual activity.

The implant is therefore a functional element integrated into the disease treatment strategy, as described in clinical reviews such as StatPearls in the definition of penile prosthesis. It is not an aesthetic-use device nor intended for penile enlargement.

Preoperative evaluation and individualized surgical planning

Each case evaluation involves a set of examinations that make it possible to understand the clinical picture individually and, based on the urologist’s experience, define the most appropriate therapeutic strategy for each patient.

Examinations and instruments for urological assessment

Evaluation of Peyronie’s disease seeks to understand disease progression, the impact on sexual activity, and the degree of erectile dysfunction. For this purpose, the urologist may use different clinical instruments and complementary examinations, according to the characteristics of each case:

Detailed clinical and sexual history: evaluation of disease duration, curvature progression, and impact on sexual activity, as well as relevant history such as pelvic surgeries and comorbidities, including diabetes.
Physical examination of the penis: performed with the penis flaccid and erect, allowing evaluation of the degree of curvature, penile length and girth, as well as identification of the location of the fibrous plaque.
IIEF-5 questionnaire: an internationally validated instrument that allows evaluation of the degree of erectile dysfunction.
Pharmacologically induced erection test (ICI): consists of intracavernosal injection of a vasoactive drug, allowing assessment of erection quality and rigidity.
Doppler ultrasound: evaluates penile morphological structures and arterial and venous blood flow.

Not all of these examinations are necessary in every case. The selection of assessments is made by the urologist, taking into account the clinical history and the characteristics of each patient.

Importance of experience in reconstructive penile surgery

Complex Peyronie’s disease represents a particular surgical challenge within urology, especially in cases requiring penile reconstruction, rather than urological procedures usually performed to treat only curvature or isolated erectile dysfunction.

This type of situation requires specific surgical planning and mastery of specialized reconstructive techniques, in order to simultaneously correct complex penile deformity and treat erectile dysfunction. Not all urologists develop clinical practice focused on the field of reconstructive penile urology.

For the patient, understanding this distinction may be important when evaluating therapeutic options. The complexity of the disease and the techniques used make differentiation between types of approach and the technical framing of the case relevant aspects in treatment planning.

Clinical outcomes, expectations, and postoperative follow-up

Understanding the goals of the procedure and the necessary follow-up helps the patient develop realistic expectations and participate actively in recovery.

Functional and anatomical goals: what can be expected

Surgical treatment seeks to address penile anatomical deformity and erectile dysfunction at the same time, in order to restore functional conditions that allow male sexual activity.

In this context, the clinical goals of surgery are:

Correction of penile anatomical deformity, allowing correction of penile deformity and preservation, when possible, of penile anatomical conditions according to the limitations of each case.
Provide penile rigidity adequate for penetration, through placement of a prosthesis.
Potential impact on aspects of quality of life related to sexual function and to the experience of the disease.

Even so, it is important to emphasize that outcomes may vary among patients, since several factors may influence the final result. For this reason, expectations should always be discussed individually with the urologist.

Clinical follow-up and progressive adaptation to the prosthesis

Surgery marks the beginning of a phase of adaptation and clinical follow-up, necessary for the overall recovery process in Peyronie’s disease.

In the weeks and months following the procedure, the patient attends follow-up appointments with the urologist, which make it possible to evaluate healing and adaptation to the new anatomical and functional condition. These appointments are also important for clarifying doubts and guiding the patient regarding the gradual return to sexual activity.

This period is also dedicated to learning how the prosthesis functions. The patient is instructed on how to handle the malleable implant or, in the case of the inflatable prosthesis, how to activate the scrotal pump to activate and deactivate the erection.

The psychological dimension of the disease also deserves attention at this stage. Peyronie’s disease may affect self-esteem, perception of masculinity, and the quality of affective relationships, so in some cases follow-up with a therapist may be beneficial.

In general, many patients gradually adapt to the new scenario over a few weeks and may progressively resume sexual activity, according to individual evolution and medical guidance.

Informed decision-making in complex Peyronie’s disease with severe erectile dysfunction

Complex Peyronie’s disease associated with severe erectile dysfunction is a specific clinical condition that requires specialized and individualized urological evaluation, and should not be self-managed or approached only on the basis of generic information.

In this context, penile prosthesis represents a therapeutic option provided for in international recommendations and described in the scientific literature for selected cases. Its indication always results from an informed and shared decision between the patient and the specialist.

For evaluation of your clinical case, contact the clinic to schedule a specialized consultation.