What is Peyronie’s Disease?
Peyronie’s disease (induratio penis plastica) is a localized connective tissue disorder of the tunica albuginea resulting from abnormal wound healing following acute or repetitive microvascular trauma during sexual activity. Non-compliant, inelastic fibrous plaques develop within the tunica, producing erect penile curvature (hinge effect), hourglass narrowing, penile shortening, and acute erectile pain (Figure 1). Approximately half of affected men experience concurrent erectile dysfunction.
Figure 1: Peyronie’s deformities resulting from tunical plaque formation. A) Dorsal plaque producing an upward hinge bend. B) Hourglass waist narrowing.
Diagnostic Evaluation
Diagnosis is established through careful physical palpation of tunical plaques, multi-angle erect home photography, and Penile Color Doppler Duplex Ultrasound to measure plaque thickness, assess calcification, and evaluate arterial and venous hemodynamics.
Biological Mechanisms of Li-ESWT in Peyronie’s Disease
Low-Intensity Extracorporeal Shock Wave Therapy (Li-ESWT) delivers focused, low-energy acoustic waves that exert mechanical shear stress on plaque tissue, activating beneficial cellular responses:
- Rapid Pain Relief: Downregulates nerve growth factor (NGF) and inflammatory neuropeptides, disrupting the hyperalgesic pathway and achieving significant relief in active-phase erectile pain.
- Plaque Remodeling: Stimulates collagenase and matrix metalloproteinase (MMP) expression, facilitating the breakdown and softening of dense, unorganized collagen bundles.
- Angiogenesis: Triggers vascular endothelial growth factor (VEGF) release, improving microvascular perfusion around the scarred tunica.
- Enhanced Erectile Function: Rejuvenates cavernous endothelium and smooth muscle, ameliorating coexisting vascular erectile dysfunction.
| Mechanism | Biological Effect | Potential Clinical Benefit |
| Mechanotransduction | Mechanical stress and microinjury activate tissue repair and scar remodeling. | May promote softening and remodeling of plaques or scar tissue |
| Antifibrotic Effects | May reduce type I and type III collagen synthesis and TGF-beta 1 signaling. | May inhibit plaque formation or the progression of fibrosis. |
| Angiogenesis | Increases VEGF and promotes new blood vessels and local microcirculation. | May support tissue repair and blood flow. |
| Anti-inflammatory Effects | Modulates IL-6, TNF-alpha, and other inflammatory signals. | May reduce local inflammation and pain. |
| Neuromodulation and Analgesia | May reduce pain signaling through nerve desensitization, NGF suppression, and hyperstimulation analgesia. | Pain relief is the most consistently reported benefit. |
| Stem Cell Activation | May activate mesenchymal stem cells and promote local tissue repair. | May support regeneration of the tunica albuginea and surrounding tissues |
Treatment Protocol
Li-ESWT is a non-invasive outpatient procedure. A specialized shock wave applicator is positioned directly over the fibrous plaque and along the penile shaft. Approximately 2,000 to 3,000 pulses are applied per session over 15 to 20 minutes. The treatment requires no anesthesia and causes negligible discomfort. A complete therapeutic course typically comprises 6 weekly sessions.
Clinical Evidence and Guidelines
Randomized controlled trials demonstrate that Li-ESWT provides marked pain resolution in over 80% of patients with acute Peyronie’s disease, along with plaque softening and improved overall sexual satisfaction. The European Association of Urology (EAU) Guidelines endorse Li-ESWT particularly for resolving penile pain during the active phase of Peyronie’s disease.
References
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- Palmieri A, Imbimbo C, Longo N, et al. A first prospective, randomized, double-blind, placebo-controlled study using low-intensity extracorporeal shock wave therapy for the treatment of Peyronie’s disease. Eur Urol. 2009;56(2):363–369.
- Palmieri A, Imbimbo C, Creta M, Verze P, Fusco F, Mirone V. Preliminary experience with extracorporeal shock wave therapy for the treatment of Peyronie’s disease. J Sex Med. 2009;6(9):238–242.
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- Fojecki GL, Tiessen S, Osther PJS. Effect of low-energy linear shockwave therapy on Peyronie’s disease: A double-blinded, randomized, placebo-controlled study. Int J Impot Res. 2017;29(3):109–114.
- Fojecki GL, Tiessen S, Osther PJS. Extracorporeal shock wave therapy (ESWT) in urology: a systematic review of outcome in Peyronie’s disease, erectile dysfunction and chronic pelvic pain. World J Urol. 2017;35(1):1–9.
- Gao L, Qian S, Lin H, et al. Meta-analysis of extracorporeal shock wave therapy for Peyronie’s disease. Int J Impot Res. 2021;33(2):167–174.
Clinical article authored and reviewed by Dr. Cheng-Hsing Hsieh.
