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A new survey has shown well over a million Australian men develop a curve in their penis during adulthood but for most of them, this is not a serious issue.
Men with a penile curve or a bend have Peyronie's disease, a condition that is little discussed and for which there are treatments but no cure.
In the fortunate few, the condition resolves naturally and disappears.
The first national survey of Peyronie's disease in Australia has just shown that 16 per cent of adult men develop this condition but that only a third of them find it problematic.
A typical curve or a bend is caused by a plaque on the lining of the erectile tissue. It's like a thickened patch on a long balloon. When blown up, the balloon curves at the point of the thickening.
Some men have more than one plaque and while these are most apparent on erection, they can also be detected on colour Duplex ultrasound.
Negative emotional impact
According to the survey, men's response to their Peyronie's disease depends largely on the severity of their curve, how it affects intercourse and on the nature of their relationships.
It can make penetration difficult and almost 30 per cent reported it had a negative emotional impact, usually on their self-confidence, self-esteem or masculinity.
For some the aesthetics were a worry and they said it affected their body image.
The survey questioned men aged 16 to 65 and found 16 per cent with some form of curvature. This is higher than the most recent figures from the United States which peg it at 9 per cent.
The full results will soon be published by Chung's AndroUrology Centre for Sexual, Urinary and Reproductive Excellence in Queensland and in the medical literature.
Eric Chung, an associate professor and consultant urological surgeon at the University of Queensland, Princess Alexandra Hospital and the AndroUrology Centre, analysed the results.
New drug approved
The results have been released as a new drug to treat Peyronie's has been approved for use in Australia. Called Xiaflex, it is the only approved medical therapy for Peyronie's in the world.
Last year it was approved by the US Food and Drug Administration and last month by Australia's equivalent, the Therapeutic Goods Administration.
Chung has been involved in the clinical trial of the drug and says while the survey was performed with an educational grant from the pharmaceutical company that markets Xiaflex, it was conducted independently by Galaxy Survey.
"While most men have a straight penis, a curve less than 10 degrees is considered normal and usually has no adverse impact," he says.
In the survey, a third of the men with Peyronie's had a curve greater than 30 degrees.
The survey began with a representational sample of 1800 Australian men across major metropolitan and rural cities but only 1100 men fitted the criteria and were finally questioned.
Among those screened out, were men who had developed their curve before the age of 16 and were likely to have congenital curvature.
Chung says 90 per cent of men with Peyronie's reported they had been living with the condition for more than a decade.
"While there can be a genetic component, the exact cause for Peyronie's remains largely unknown," says Chung who is also a co-author of the 2015 International Consultation on Sexual Medicine guideline on Peyronie's Disease endorsed by the International Society of Sexual Medicine.
Tissue damage
The general consensus view, however, is that Peyronie's can develop following trauma during which the erect penis is bent or hits up against a hard surface.
This can cause a small tear inside the penis, some internal bleeding and a build-up of scar tissue which can often be felt through the skin as a flat plaque.
It reduces elasticity and over time may gather calcium and become harder.
The plaque commonly occurs on the top of the penis, causing an upward bend during erection. If it occurs on the side it can cause side curvature.
It can also occur underneath or extend around the penis, causing a narrowing, or an hour-glass deformity, in the shaft.
In some men Peyronie's causes painful or soft erections. It also has the potential to shrink or shorten the penis.
Older men are at higher risk because older tissue is more easily injured and is less likely to heal. Others at risk include men who have the connective tissue disorder called Dupuytren's contracture, a thickening in the hand that pulls the fingers inwards.
Men in the survey had difficulty tracing the origin of their curve. Only 5 per cent could say with certainty that it appeared soon after an injury. While 48 per cent were unsure, 47 per cent were adamant there had been no injury.
The survey quantified the impact of Peyronie's showing: one in four was bothered by the way their penis looked; one in 10 reported decreased sexual activity; and one in five experienced difficulty with intercourse.
While only one in 10 men sought professional advice, the rest trawled the internet for information.
Married men or those with a girlfriend were twice as likely to be bothered by pain or discomfort on erection compared to men without a relationship.
While many felt their curve affected the strength of their erection, some discussed this with their partner but some were too embarrassed to broach the subject.
Chung says in 20 per cent of men, a curve will disappear spontaneously within six months. After that natural resolution is unlikely. In 40 per cent of men it stays the same and in the remainder it gets worse.
Treatment options
The new drug Xiaflex has been approved for use in men with a curve greater than 30 degrees on erection.
Chung says it involves three to four treatment cycles delivered six weeks apart with each cycle consisting of two single injections into the plaque over a week. The injections break down the build-up of collagen in the plaques.
They cost $1200 each and after each shot, the urologist bends the penis in the opposite direction of the plaque, hoping to break it and encourage the drug into crevices it may not have reached.
Men are taught to do similar penile modelling exercises at home.
He says the best results are achieved in the first three to six months after plaque formation and can be slow to appear. The process has risks and safety warnings are unusually prominent on the Xiaflex website.
Other treatments include traction therapy to stretch the penis which can help a little and shock wave therapy which has had marginal success.
Surgery is often the last resort but produces the fastest, most reliable and sustained result. It has risks too and often shortens the penis.
When all else fails or there is coexisting erectile dysfunction, Chung says some men resort to a penile prosthesis implant.