Interview With Dr. Joel Gelman
Dr. Joel Gelman is the Director of the Center for Reconstructive Urology and Clinical Professor in the Department of Urology at the University of California, Irvine.
Dr. Gelman areas of expertise include urethral stricture disease and urethroplasty, Peyronie's disease and other disorders of penile curvature (diseases the cause a bent penis), hypospadias, erectile dysfunction including penile implant surgery, and other disorders of the male urethra and external genitalia.
Dr. Joel Gelman has performed over 1,400 urethral-penile reconstructive surgeries, and his practice is limited to his area of expertise in male urethral and genital / penile reconstructive surgery.
Dr. Gelman is a Diplomate of the American Board of Urology and a member of the Board of Directors of the Society of Genitourinary Reconstructive Surgeons.
I'm honored that Dr. Gelman agreed to be interviewed by My Peyronie's.
Dr. Joel Gelman, please tell us a little bit about your background and your experience of treating patients with Peyronie's disease
After completing my Urology Residency at UCLA Medical Center, I pursued specialized Fellowship training at the Devine Center for GU Reconstruction where my mentor was Dr. Gerald Jordan. The Fellowship was at the time, the only Fellowship 100% exclusively devoted to male penile and urethral-genital disorders, and a high percentage of patients had Peyronie’s Disease (PD).
After completing my Fellowship, I was recruited to join the Faculty in the Department of Urology at the University of California, Irvine where I established the Center for Reconstructive Urology. This was the first tertiary care center in Southern California dedicated to the treatment of men with penile and urethral disorders.
For the past 17 years, I have served as Director of the Center for Reconstructive Urology, and I am currently a Professor of Urology at the University of California, Irvine. My practice has always been 100% exclusively devoted to my sub-specialty. Men with PD are commonly referred by their Urologists to our Center for evaluation and treatment. To date, over 300 Urologists including Urologists at other major University Medical Centers have referred patients to our center for treatment of male penile-urethral disorders.
Roughly, how many Peyronie's patients do you treat each year?
We see over 100-150 new patients with penile curvature each year. It is important to understand that not all penile curvature is caused by PD as other causes of curvature are chordee and congenital penile curvature.
What is the average age of your Peyronie's patients?
Most men who have PD are in their late 40s and 50s. Those who are much younger and report life long curvature may think they have PD (an acquired condition) but they actually have a congenital cause of curvature.
Approximately, how many of your patients fall into each of the following groups: mild, modern, and severe Peyronie's condition?
I find it hard to stratify our patients into specific categories given that curvature is a spectrum, a given degree of curvature is more disabling for one man than another, and a given degree of downward curvature is more disabling than upward curvature.
A significant percentage of our patients are men who come to our Center after failed surgery elsewhere, and patients who are referred by their Urologists to us for surgery after medical management failed.
In your opinion, are some men more likely than others to develop Peyronie's disease?
We do not know what causes PD with certainty. However, a certain percentage of men with PD have associated contractures in their hands (Dupuytren's contractures) suggesting that in some men, there may be a genetic factor. However, most men with PD do not have these associated contractures. It is also thought that mild penile trauma (example female superior position sex) can be a factor, but again, many men do not have such a history.
Perhaps some men reading this question will be believe that perhaps they may have done to cause their curvature, or may be wondering what they could have done to prevent the disease. What is important is for these men to understand that they did not do anything to cause PD.
How important is early diagnosis in your opinion? Can men expect better results the sooner they start treatment and why?
Several questions in this interview relate to medical management. My mentor once said that medical management is what doctors and patients do to entertain themselves as the disease takes its natural course. That statement was made because in there have been and continue to be many non-surgical treatments touted as effective for the early management of PD that are not really effective at all. Vitamin E is just one example. When men have immature early Peyronie’s Disease, it is natural for them to want to be treated. That is normal.
When a man first develops PD, this is called the early, acute, immature phase. The early phase is characterized by pain (not always), curvature, the development of a plaque within the penis, and possible “shrinkage” of the penis. Then, over a period of months (this can take well over 1 year), the disease “runs it’s course” and stabilizes. Stable mature PD is characterized by pain resolution and stability of the curvature (no change for 6 months). As the disease progresses from immature to stable, there can be curvature resolution, no change in curvature, or worsening curvature. It would be nice if medical management were to positively influence the disease progression in favor of less or no curvature as the disease progresses to stable PD. However, unfortunately, medical management does not seem to offer a significant benefit.
If a man with PD wants to pursue medical management, then that is an option. However, I for the man who chooses observation and then will has curvature progression as the disease stabilizes, that man should look back and think he could have maybe prevented having the increased curvature if only he would have taken pills, used expensive topical creams sold on the internet, used traction devices, or had penile injections.
Can you describe the non-surgical treatments you recommend to your patients? What influences which treatments you recommend?
Back when I started my practice over 17 years ago subsequent to my Fellowship Training, I used to suggest Vitamin E, only because I thought it would not hurt, and hopefully it would help based on no excellent date suggesting efficacy. Now that is it clear to me that Vitamin E has no effect, I do not mention it. There were other drugs that were popular at the time like Potaba and Colchicine, but I did not consider these medications effective either along with Verapamil cream or injections.
Several years ago, colleague indicated to me that in his personal experience, Trental (Pentoxyphylline) may be helpful in patients with painful erections with immature disease. I have offered that to many of my patients, and some have had subsequent improvement. However, it is the rule that pain resolves and the curvature stabilizes regardless of medical treatment. Therefore, those patients may have had the same result without treatment.
Have you used Xiaflex and / or Verapamil injections? If so, what is your experience of them? How does Xiaflex compare to Verapamil in your opinion?
Xiaflex is the new FDA approved PD treatment being marketed as an effective non-surgical treatment to correct curvature through a series of injections into the plaque of the penis. At this time, the data suggesting efficacy comes mostly from clinical trials by the company that manufactures and sells the product. I am an approved provider and our hospital at the University of California, Irvine is an approved center able to offer Xiaflex.
However, I want to share with you a story. Shortly after Xiaflex was FDA approved, I attended Urology Society Meeting (audience was Urologists) where the speaker was sponsored by the manufacturer. The slides presented were provided to the speaker by the company, and had the company logo on each slide. Naturally, the talk discussed Xiaflex very favorably. What was most interesting is that one of the slides contained Peyronie’s Surgery illustrations taken from my website and professional publications. Those color illustrations were drawings I designed with a medical illustrator and paid for out of my own pocket for teaching purposes. They were used without my knowledge or consent. I prepare my own talks and receive no compensation when I am an invited speaker. Financial relationships between doctors and industry are common and promote education and research progress, and I know a number of very well respected Urologists who have industry ties. However, I think that when speakers are provided their talks on a product by the manufacturer, this creates a bias. I personally have never accepted money from industry.
That being said, I am hopeful that Xiaflex will reduce the curvature in a significant percentage of men who have stable PD, and have no reason to discourage men with stable PD from pursuing Xiaflex. I do not think Verapamil is a very effective agent.
What do you recommend for men that also suffer from low erection quality / erectile dysfunction?
There is a clear association between erectile dysfunction (ED) and PD in many but not all cases. When a man has both, our initial focus is on treating the ED. Some doctors suggest penile implants to patients with both as though there is no reasonable alternative.
That is certainly an option, but I believe that a better option in many cases when the ED can be non-surgically treated, is to treat the ED, and then correct the curvature with surgery for curvature correction (no implant). If the ED is truly unresponsive to all medical therapy, an implant is the best option.
What types of surgery do you perform and what is your experience of each?
I perform both plication and graft surgery. I believe that doctors who perform Peyronie’s surgery should have specific training and experience with both plication and graft techniques so they can select which operation is best for a particular patient. In my case this includes a formal Fellowship. Not all Fellowships offer the same training. My Fellowship was exclusively devoted to male penile-urethral reconstructive surgery, which included a high volume of both graft and plication surgery.
When we evaluate men with PD, surgery is an option only when the disease is stable and mature. Grafts lengthen the short side and plication shortens the long side. One would think that every man would prefer a graft given that it is natural for a man to not want penile shortening. However, graft surgery carries a high risk of ED in certain patients. These patients include men with any pre-existing ED or when the graft is placed on the ventral (undersurface of the) penis.
Certainly a man does not benefit from a penis that is straight when erect if he can no longer achieve an erection. Therefore, we generally perform a penile duplex ultrasound before and after a pharmacologically induced erection prior to surgery to evaluate the vascular status of the penis and evaluate the curvature and length.
Some studies indicate that with plication, a certain percentage of patients experience shortening. That never made sense to me. When a plication is performed, the long side will be shortened 100% of the time. The long side is shortened on purpose so that both sides are equal. In reality, in many cases, plication tilts the penis straight without causing disabling shortening while correcting disabling curvature. I therefore believe that plication is an excellent options for many patients.
Moreover, the disease itself causing some global shortening, just on one side more than the other, and even with a graft, if a patient expects to have the exact length as prior to the disease, he may be disappointed. Our goal is to provide the patient with a penis that is straight and functional, and our approach is individualized.
Anything you would like to add?
I think that the main points for men with Peyronie’s Disease are that this can be treated, and no matter how badly the penis becomes curved, it can be straightened. The sex life is not over.
However, a man with PD must be patient as the most effective option for the treatment for severe curvature is surgical correction, and that surgery is best done when the disease has been stable for 6 months. It can take many months for the disease to stabilize and so that requires a lot of patience. It is a long tunnel, but there is light at the end.
Dr. Joel Gelman, thank you very much for taking the time to do this interview with My Peyronie's. For more information about Dr. Gelman, visit The Center for Reconstructive Urology