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No one notices your problem — except you and your partner. It's painful and makes having sex difficult. Your relationship may have become strained because of it.

Peyronie's (pa-ro-NEEZ) disease causes an uncommon sexual dysfunction that results from a bent penis during erection. The disease is characterized by a hard, fibrous layer of scar tissue (plaque) that usually develops under the skin on the upper or lower side of the penis. When the penis is erect, the scar tissue pulls the affected area off at an angle, causing a curved penis. The plaque, formed by thickened layers of erectile tissue, is noncancerous (benign).

Francois de la Peyronie, a French surgeon, first described Peyronie's disease in 1743. Because Peyronie's disease involves deformity of an erect penis and may impair sexual intercourse, doctors have historically classified the condition as a form of impotence, currently referred to as erectile dysfunction (ED). Although Peyronie's disease can involve ED, doctors recognize ED as only one factor that may or may not be associated with the disorder.

Sometimes Peyronie's disease improves without treatment, so your doctor may initially recommend a wait-and-see approach. Other options for treatment of Peyronie's disease involve nonsurgical and surgical approaches.

The signs and symptoms of Peyronie's disease may appear overnight or develop more slowly. These may include:

• Painful erection
• A bend or curve in your penis during erection
• Inflammation under the skin of your penis that develops into hardened scar tissue
• A thick band of hard tissue on one or more sides of your penis
• Narrowing of the diameter of your penis during erection
• Impaired ability to obtain an erection (erectile dysfunction)

Scar tissue that develops on the top of the penis will cause the penis to bend upward. Plaque on the underside of your penis will cause it to bend downward. More rarely, hardening may occur on both sides of the penis, causing indentation and shortening.

In many cases, pain caused by Peyronie's disease may decrease after a short period of time. However, the curvature may persist even if the pain subsides. In some men with a milder form of the disease, inflammation may improve without causing a lot of pain or permanent bending.

Doctors and researchers don't completely understand what causes Peyronie's disease. A number of theories exist, including:

• Injury to the penis. Trauma to the penis from being hit or bent abnormally while erect or during intercourse may cause small tears in the tissue. It may also cause small blood vessels in the penis to rupture and bleed internally. Abnormal healing can result in the development of hard, thickened scar tissue (plaque) under the skin of the penis. With repetitive trauma, the plaque may develop tough fibrous tissue (fibrosis) or calcium deposits (calcification) and result in the deformity.
• Autoimmune disorder. Some studies suggest that Peyronie's disease may be an autoimmune disorder. A man's immune system may respond abnormally and cause plaque to form in the penis. However, Peyronie's disease isn't related to other autoimmune diseases, such as rheumatoid arthritis or lupus.
• Collagen abnormality. Peyronie's disease may be caused by an abnormality in the substance that builds and remodels connective tissue (collagen).
• Medications. Some drugs list Peyronie's disease as a possible side effect. Most of these drugs belong to a class of blood pressure and heart medications called beta blockers. These drugs are also used to treat glaucoma, multiple sclerosis and seizures. Developing Peyronie's disease as a side effect of these drugs is rare. Check with your doctor before discontinuing any prescribed drug.

Although injury to the penis may explain sudden (acute) cases of Peyronie's disease, cases that develop slowly or disappear quickly with no apparent trauma to the penis remain unexplained.

Peyronie's disease is a relatively uncommon disorder. The following factors may increase your risk:

• Age. Aging may diminish penile elasticity, increasing the chance of injury and the development of Peyronie's disease.
• Heredity. Heredity may be an important factor in determining who acquires Peyronie's disease, although it's not the only factor.
• Other conditions involving hardened tissues. Some men with Peyronie's disease experience hardened tissues in other areas of the body, such as the hands or the feet. A condition known as Dupuytren's contracture, which is a cord-like thickening across the palm that causes the fingers to pull inward, also may be associated with Peyronie's disease.

See your doctor if you're unable to have intercourse without bothersome pain or difficulty due to a bend or curve in your penis during erection. Treatment for Peyronie's disease often consists of methods that will help you remain sexually active. Early education about the disease and its course can help you manage its symptoms effectively.

Doctors diagnose Peyronie's disease by a physical examination. Hard plaque can be felt in your penis with or without an erection. It may be necessary to inject medication into your penis to induce an erection for proper evaluation. Ultrasound of the penis also may reveal fibrous tissue in the penis.

Peyronie's disease can make intercourse painful, difficult or even impossible. Emotional distress can put a strain on your marriage or relationship and make attempts at sexual activity with your partner stressful and frustrating.

Because the course of Peyronie's disease differs from man to man and some men experience improvement without treatment, doctors often initially recommend a wait-and-see approach. Your doctor may suggest monitoring the progression of the disease for nine to 12 months by assessing plaque formation, penile curvature and erectile function before attempting treatment. Some treatments — nonsurgical and surgical — can increase a man's risk of ED.

Nonsurgical methods
If Peyronie's disease doesn't improve without treatment, your doctor may suggest a nonsurgical treatment:

• Vitamin E. Researchers have reported improvements in Peyronie's disease when vitamin E is taken orally, yet the effectiveness of vitamin E therapy has yet to be proved in controlled studies. Similar research exists on potassium aminobenzoate (Potaba), a vitamin B-complex. The benefit of potassium aminobenzoate also remains unproved.
• Intralesional injections. Your doctor can inject drugs such as collagenase or calcium channel blockers, such as verapamil, directly into the plaque. These drugs are intended to break down scar tissue deposits and return the tissue-building process to normal. You'll receive multiple injections over a period of up to three months. The success of intralesional injections varies. Intralesional injection of steroids, such as cortisone, has caused harmful side effects to healthy penile tissues.

Surgery
If other methods of treatment don't help and your penis is still curved or bent when erect, surgery may be an option. Doctors usually suggest surgery when unacceptable appearance, pain during intercourse and poor erection quality persist for one to two years or longer. Surgery is generally effective at restoring normal erections, although each surgical method can cause unwelcome side effects such as partial loss of erection or shortening of an erect penis.

Common surgical methods include:

• Plaque excision. The plaque is removed and replaced with a patch of skin from the pubic area.
• Nesbit plication. Tissue on the opposite side of the penis is removed or pinched, canceling the bending effect.
• Plaque incision with saphenous vein graft. Several linear cuts are made in the plaque, which allows straightening. The cut plaque is then covered with a grafted vein.
• Penile prosthesis. An implanted device is used to straighten and increase the rigidity of the penis.

There's no known prevention for Peyronie's disease. It's possible that the problem may begin with trauma to the penis from being hit or bent abnormally when erect or during sexual intercourse. Avoiding injury to your penis when erect may prevent the development of Peyronie's disease. However, trauma to the penis doesn't explain all cases of the disorder.

Peyronie's disease can become a source of mental and emotional stress for you and your partner. Having the disease shouldn't be seen as a reflection of your health, virility or masculinity. If you have Peyronie's disease that has progressed to include erectile dysfunction, remember that your partner may see your inability to have intercourse as a sign of diminished sexual desire. Your reassurance that this isn't the case can help your relationship.

To effectively manage and treat Peyronie's disease, strengthen your relationship with your partner. Try to communicate openly and honestly about your condition. As a couple, you may want to seek counseling to confront concerns you have about Peyronie's disease and to learn how to deal with your feelings. When you maintain open communication as a couple and work together as a team, treatment often is more successful.