Creating Waves of Awareness
Peyronie’s Disease and Homoeopathy
© Dr. Rajneesh Kumar Sharma M.D. (Homoeopathy)
Dr. Swati Vishnoi B.H.M.S.
Dr. Preetika Lakhera B.H.M.S.
For well formatted and illustrated article, please see attached file-
Corpus cavernosum.. 3
Corpus spongiosum.. 4
Angle of the penis 5
Physiology of erection. 6
Full erection phase. 6
Rigid erection phase. 6
Relaxation phase. 6
Types of erection. 6
Acute inflammatory phase. 7
Fibrotic phase. 7
Injury to the Penis 8
Autoimmune diseases 8
Connective Tissue diseases 8
Family history of Peyronie’s disease. 8
Risk factors 8
Standalone Peyronie disease. 9
Peyronie Disease associated with systemic diseases 9
Medical and Family History. 9
Physical examination. 9
Differential Diagnosis 10
Surgical Treatment 10
Nonsurgical Treatment 10
Lifestyle Changes 10
Homoeopathic treatment 11
Repertory of Peyronie Disease. 11
Peyronie disease is a connective tissue disorder, characterized by the formation of a fibrotic lesion or plaque (Psora/ Sycosis) in the tunica albuginea, which leads to penile deformity, preventing normal stretching, affecting the size and shape of the erect penis as curvature which can make vaginal intromission painful, difficult, or impossible.
Peyronie’s disease begins with inflammation, or swelling, which can become a hard scar.
Origin: Named after François Gigot de La Peyronie (1678–1747), A French surgeon
Synonyms: Peyronie's disease, Peyronie disease, induratio penis plastica (IPP), chronic inflammation of the tunica albuginea (CITA)
Common in 55-60 years.
The penis is the male sex as well as excretory organ. It has following parts-
It is head of the penis and covered with pink, moist tissue called mucosa. Covering the glans is the foreskin or prepuce. In circumcised men, the foreskin is surgically removed and the mucosa on the glans transforms into dry skin.
These are two columns of tissue running along the sides of the penis. Blood fills this tissue to cause an erection.
It is a column of sponge-like tissue running along the front of the penis and ending at the glans penis. It fills with blood during an erection, keeping the urethra open.
The urethra runs through the corpus spongiosum, conducting urine out of the body.
The angle of the erect penis or erection angle is determined by its size and its attachment to the puboischial rami (the crura) and the anterior surface of the pubic bone (the suspensory and funiform ligaments). In men with a long heavy penis or a loose suspensory ligament, the angle usually will not be greater than 90 degrees, even with full rigidity.
The penile erectile tissues used in erection process involve-
In the flaccid state, these smooth muscles remain tonically contracted, allowing only a small amount of arterial flow for nutritional purposes. Erection needs a particular series of events-
An erection begins with sensory or mental stimulation, or both. The stimulus may be physical contact or a sexual image or thought (Psora).
When the brain senses a sexual urge, it sends impulses to local nerves in the penis that cause the muscles of the corpora cavernosa to relax (Psora). As a result, blood flows in through the arteries and fills the spaces in the corpora cavernosa like water filling into a sponge (Psora).
When men get sexually stimulated, the nervous system releases nitric oxide (NO) that stimulates enzyme that produces cGMP (Sycosis) that relaxes the smooth muscle cells. This causes the arteries in the penis to dilate (Psora), allowing the blood to flow more easily into the penis. It also causes the erectile tissue itself to fill with blood. Together this results in an erection. cGMP is normally broken down by phosphodiesterase type 5 (Syphilis). This results in relaxation of these smooth muscles. Following events take place in process of erection-
Psychogenic erection is a result of audiovisual stimuli or fantasy (Psora). Impulses from the brain modulate the spinal erection centers (T11-L2 and S2-S4) to activate the erectile process (Psora).
Reflexogenic erection is produced by tactile stimuli to the genital organs (Psora). The impulses reach the spinal erection centers; some then follow the ascending tract, resulting in sensory perception, while others activate the autonomic nuclei to send messages via the cavernous nerves to the penis to induce erection (Psora). This type of erection is preserved in patients with upper spinal cord injury.
Nocturnal erections occur mostly during rapid-eye-movement (REM) sleep, in which there is-
The mechanism that triggers REM sleep is located in the pontine reticular formation. Now-
This differential activation may be responsible for the nocturnal erections during REM sleep.
Trauma to the tunica albuginea allows release of transforming growth factor (Psora), activating reactive oxygen species like nitric oxide, which allows collagen deposits and calcification of the plaque that causes the deformity (Psora/ Sycosis).
Penile injuries may rupture blood vessels, which leads to bleeding and swelling inside the layers of the tunica albuginea (Pseudopsora). Swelling inside the penis blocks blood flow through the layers of tissue inside the penis (Causa occasionalis). When the blood flows insufficiently, clots can form and trap immune system cells (Causa occasionalis). As the injury heals, the immune system cells may release substances as nitric oxide that lead to the formation of too much scar tissue by deposition of collagen fibers (Psora/ Sycosis). The scar tissue builds up and forms a plaque inside the penis (Psora/ Sycosis). The plaque reduces the elasticity of tissues and flexibility of the penis during erection, leading to curvature (Causa occasionalis). The plaque may further harden because of calcification.
There are two phases of the disease manifestation-
Acute inflammatory phase
It may be associated with pain in the flaccid state or painful erections and a palpable nodule or plaque in the tunica of the penis and typically a penile curvature begins to develop (Psora/ Sycosis/ Syphilis).
With the formation of hard palpable plaques calcification may superimpose, resulting in disease stabilization (Sycosis). Pain is present in early stages of the disease which tends to resolve with time in 90% of men, usually after one year of the disease onset.
Repetitive microvascular injury or trauma to the tunica albuginea leads to scarring (Psora/ Sycosis/ Syphilis). A prolonged inflammatory response results in the remodeling of connective tissue into a fibrotic plaque (Sycosis). Penile plaque formation can result in curvature (Causa occasionalis).
Injuries may be caused by vigorous sexual or nonsexual activities. Hitting or bending the penis may injure the tissues inside as during sex, athletic activity, or an accident. (Causa occasionalis)
Inappropriate angle of insertion of penis into vagina causing undue bending
When woman is on top she usually controls the movement with her entire body weight landing on the erect penis, not being able to interrupt it when the penis suffers a wrong way penetration, because the harm is usually minor in woman with no pain but major in the penis. (Causa occasionalis)
When the immune system attacks cells in the penis, inflammation can cause scarring (Psora/ Sycosis/ Syphilis).
A man whose father or brother has Peyronie’s disease may have an increased chance of getting the disease. (Syphilis)
Age-related changes in the elasticity of tissues in the penis may cause it to be more easily injured and less likely to heal well. (Psora/ Syphilis)
When the disease develops due to local causes.
When it is associated with other systemic or autoimmune disorders.
Symptoms may be mild to severe which may develop slowly or quickly. often, the pain decreases over time, but the curve in the penis may persist in severe cases.
It based on-
Medical and Family History
Inability to perform sexual intercourse
Not all lumps in the penis are Peyronie disease. Small bumps, cysts and pimples on the outside of the penis and scrotum are also quite common and usually harmless.
Penile cancer usually starts with a tender spot or wart-like bump on the outside of the penis and there may be bleeding and unusual discharge from the penis.
Conservative treatment for Peyronie’s disease usually resolves it. Surgery is only indicated in patients with penile curvature that does not allow satisfactory intercourse.
Target is to decrease penile curvature, plaque size, and inflammation.
Peyronie Disease acon. agar. Agav-a. AGN. all-c. alum-p. Alum. Alumn. am-c. am-m. ambr. Anac-oc. Anac. ANAN. androc. ang. ant-c. Ant-t. anth. anthraco. apis arg-met. ARG-N. ARN. ARS. arund. asaf. asar. aster. Aur-m. aur-s. Aur. bamb-a. Bar-c. Bell-p. bell. berb. borx. both-ax. bov. bry. BUFO calad. calc-f. Calc-p. CALC. calen. camph-br. Camph-mbr. Camph. Cann-i. CANN-S. Cann-xyz. CANTH. CAPS. Carb-an. CARB-V. carc. caust. cham. Chel. Chin. chir-fl. chlol. cic. cimx. Cina CLEM. Coc-c. cocc. cod. Coff. Colch. coloc. Con. cop. corn. croc. crot-h. Cub. cund. cupr. cupre-l. cur. cycl. cyna. cyt-l. dendr-pol. Dig. Dios. diphtox. dros. dulc. erig. ery-a. eug. euph. falco-pe. ferr-i. Ferr. FL-AC. gast. Gels. gink-b. gins. glon. GRAPH. grat. guaj. ham. hell. helon. hep. hydr. hyos. Hyper. ign. Iod. ip. jac-c. jug-r. junc-e. kali-bi. Kali-br. Kali-c. KALI-CHL. kali-i. Kali-m. kali-n. kali-p. kali-sil. kalm. kola kreos. LACH. lat-m. Laur. led. limen-b-c. loxo-lae. Lup. Lyc. lyss. m-ambo. m-aust. mag-c. Mag-m. maland. mang. Med. Meph. merc-c. MERC. mez. mill. mosch. mur-ac. Mygal. naja nat-c. nat-m. nat-p. NIT-AC. nux-m. Nux-v. oena. ol-sant. onis. Onos. Op. ORIG. orot-ac. ozone par. petr-ra. petr. Petros. Ph-ac. Phos. Phyt. PIC-AC. pip-m. pip-n. PLAT. Plb. plut-n. podo. psor. Puls. pyrog. ran-b. ran-s. rhod. Rhus-t. ruta sabad. sabal Sabin. sal-n. samb. sars. sec. sel. seneg. SEP. SIL. sin-n. Spig. spong. squil. Stann. STAPH. stict. still. Stram. sul-ac. SULPH. sumb. syph. Tab. tarent. TER. teucr. thala. ther. thiosin. THUJ. tritic-vg. Tub. tus-p. Ust. vac. valer. vanil. verat. viol-t. Vip. visc. wildb. x-ray yohim. zinc-pic. zinc. Zing.
GENERALS - WOUNDS - granulations, proud flesh Alumn. Anac-oc. Anac. Ant-t. ARS. Calc. Calen. chir-fl. cund. hydr. Kali-chl. Kali-m. Lach. Merc. nit-ac. Sabin. SIL. SULPH. thuj.
MALE GENITALIA/SEX - COITION – painful arg-n. borx. calc. cupr. ferr. kali-c. kreos. lyss. merc-c. nat-m. plat. sabal sep. sulph. thala.
MALE GENITALIA/SEX - ERECTIONS - continued - curvature of penis, with canth.
MALE GENITALIA/SEX - ERECTIONS - continued – painful acon. ARG-N. aur-m. bry. Camph. Cann-i. CANN-S. CANTH. CAPS. chlol. Colch. con. cop. Cub. cur. dig. ery-a. fl-ac. hep. jac-c. kali-br. KALI-CHL. kali-i. Kali-m. merc-c. Merc. Mygal. nat-c. Nit-ac. Nux-v. Petros. phos. pip-n. PULS. sabad. sep. still. TER. Thuj. zing.
MALE GENITALIA/SEX - ERECTIONS - easy, too Con. ferr-i. ferr. kali-c. lyc. nux-v. Phos. Pic-ac. Plat. Plb. rhod. sabin. sumb. wildb.
MALE GENITALIA/SEX - ERECTIONS - excessive - thoughts, during sexual cop. PIC-AC.
MALE GENITALIA/SEX - ERECTIONS – excessive Aur-m. CANTH. cop. FL-AC. Graph. nat-m. op. Ph-ac. Phos. Pic-ac. plat. sabin. staph.
MALE GENITALIA/SEX - ERECTIONS – frequent acon. agar. Agn. alum-p. alum. alumn. am-m. anth. anthraco. apis arund. aster. Aur-m. aur-s. Aur. bell. berb. cann-i. cann-s. Cann-xyz. Canth. Caps. carb-v. caust. cham. Chel. chin. cic. cimx. clem. Coc-c. cod. coloc. corn. cyna. cyt-l. Dig. Dios. erig. Ferr. fl-ac. graph. ham. helon. jug-r. kali-c. kali-n. kalm. lach. lat-m. Laur. lyc. Mag-m. Med. merc-c. merc. mez. mur-ac. nat-c. Nat-m. nat-p. nit-ac. nux-v. onis. petr. ph-ac. Phos. pic-ac. plb. Puls. ran-b. rhus-t. sabad. sabin. sec. sep. sil. sin-n. Spig. sumb. Tab. ther. ust. valer. visc. zinc.
MALE GENITALIA/SEX - ERECTIONS – fruitless aur. con. gins. Phos. plat. Sep.
MALE GENITALIA/SEX - INJURIES – Penis mill.
MALE GENITALIA/SEX – INJURIES Arn. Calen. con. Hyper. mill. Rhus-t. Staph.
MALE GENITALIA/SEX - MASTURBATION; disposition to – excessive Alum. bell. CALC. CARB-V. Chin. Onos. orot-ac. Stram. tub.
MALE GENITALIA/SEX - MASTURBATION; disposition to agar. agn. Alum. alumn. ambr. Anac. ANAN. androc. Apis arg-met. arg-n. Aur. Bar-c. Bell-p. bell. BUFO calad. Calc-p. calc. cann-i. cann-xyz. CANTH. CARB-V. carc. Caust. Chin. Cina cocc. Coff. Con. dendr-pol. Dig. dios. dros. dulc. falco-pe. Ferr. Gels. grat. hyos. Kali-br. Kali-c. kali-p. kola LACH. Lyc. Med. Meph. merc. mosch. nat-m. Nux-v. Op. ORIG. ozone petr-ra. Ph-ac. Phos. Pic-ac. PLAT. Plb. podo. Puls. sal-n. sec. sel. SEP. sil. Stann. STAPH. stict. stram. Sulph. tarent. thuj. Tub. Ust. vanil. zinc.
MALE GENITALIA/SEX - PENIS; complaints of acon. agar. agn. Alum. am-c. am-m. ambr. anac. ang. ant-c. ant-t. ARN. ars. asaf. asar. aur. bar-c. bell. borx. bov. bry. calc. camph. CANN-S. Cann-xyz. CANTH. Caps. carb-an. Carb-v. caust. cham. chel. chin. cic. CLEM. cocc. coff. colch. coloc. Con. croc. cupr. cycl. dig. dros. dulc. euph. ferr. Graph. guaj. hell. hep. ign. iod. ip. kali-c. kali-n. kreos. lach. laur. led. Lyc. m-ambo. m-aust. mag-c. mag-m. mang. MERC. mez. mosch. mur-ac. nat-c. nat-m. Nit-ac. nux-m. NUX-V. op. par. petr. ph-ac. Phos. plb. PULS. ran-s. rhod. rhus-t. ruta sabad. sabin. samb. sars. sec. sel. seneg. SEP. sil. spig. spong. squil. stann. Staph. stram. SULPH. teucr. THUJ. verat. viol-t. Zinc.
SKIN - CICATRICES – hard calc-f. dros. fl-ac. Graph. kali-bi. sil.
SKIN - CICATRICES – painful all-c. asaf. aster. bamb-a. both-ax. calc. calen. Carb-an. carb-v. con. crot-h. eug. gink-b. graph. Hyper. kali-c. kali-sil. Lach. limen-b-c. lyss. Mag-m. Nat-m. Nit-ac. nux-v. phos. plut-n. SIL. staph. sul-ac. tritic-vg.
SKIN – CICATRICES bell-p. calc-f. carb-v. caust. chir-fl. crot-h. dros. Fl-ac. gast. glon. graph. hyper. iod. kali-bi. kali-c. lach. Merc. mez. naja nat-m. nit-ac. ozone petr. phos. Phyt. pyrog. sabin. Sil. sul-ac. syph. thiosin. vip.
SKIN – KELOID alum. ars. bell-p. calc-f. calc. calen. carb-v. carc. caust. crot-h. cupre-l. diphtox. dros. Fl-ac. gast. GRAPH. hyper. Iod. junc-e. kali-bi. lach. loxo-lae. lyss. maland. merc. NIT-AC. nux-v. phos. phyt. psor. rhus-t. sabin. SIL. sul-ac. Sulph. thiosin. thuj. tub. vac. Vip. x-ray
URETHRA – CHORDEE acon. Agav-a. AGN. Anac. ARG-N. aur-m. bell. berb. bry. camph-br. Camph-mbr. Camph. Cann-i. CANN-S. CANTH. CAPS. chlol. clem. Colch. con. cop. Cub. cur. dig. ery-a. fl-ac. gels. hep. hyos. jac-c. Kali-br. KALI-CHL. kali-i. kali-m. Lup. merc-c. Merc. Mygal. nat-c. Nit-ac. Nux-v. oena. ol-sant. Petros. phos. Pic-ac. pip-m. pip-n. PULS. sabad. sabin. sal-n. sep. sin-n. still. stram. TER. Thuj. tus-p. yohim. zinc-pic. Zing.
Adult Sexual Dysfunction > Sexual Pain Syndromes CURRENT Diagnosis & Treatment: Family Medicine, 4e... Sexual pain syndromes can negatively affect arousal. Sexual pain syndromes occur in 14% of women and 3% of men in the general population, and >70% of samples of female patients. Peyronie plaques or other penile deformity, priapism, and lower urinary tract symptoms (LUTSs) can be etiologic...
Chapter 3. Differential Diagnosis: Symptoms, Signs, and Conditions > Impotence (Erectile Dysfunction) Clinician's Pocket Reference: The Scut Monkey, 11e..., anticholinergics; addictive medications: alcohol, narcotics; antipsychotics; antiandrogens: histamine H 2 blockers, finasteride, LHRH analogues, spironolactone, others); history of priapism, Peyronie disease, testicular failure, hyperprolactinemia ...
Chapter 39. Male Sexual Dysfunction > Cavernosal Disorders Smith and Tanagho's General Urology, 18e... Cavernous veno-occlusive dysfunction (CVOD) may result from a variety of pathophysiologic processes. Degenerative changes (Peyronie's disease, aging, and diabetes) and traumatic injury to the tunica albuginea (penile fracture) can impair the compression of the subtunical and emissary veins...
Chapter 4. Physical Examination of the Genitourinary Tract > Palpation Smith and Tanagho's General Urology, 18e... Palpation of the dorsal surface of the shaft may reveal a fibrous plaque involving the tunica albuginea covering of the corpora cavernosa, typical of Peyronie's disease. Tender areas of induration felt along the urethra may signify periurethritis secondary to urethral stricture. ...
Chapter 41. Disorders of the Penis & Male Urethra > Peyronie's Disease Smith and Tanagho's General Urology, 18e... in the corpora cavernosa. Additional methods include radiation therapy and injection of steroids, dimethyl sulfoxide, or parathyroid hormone into the plaque. The success of such treatments is poorly documented. Peyronie's disease (plastic induration of the penis) was first described in 1742 and is a well...
Chapter 6. Radiology of the Urinary Tract > Miscellaneous Urologic Angiography Smith and Tanagho's General Urology, 18e.ectional methods, these procedures are rarely used. Although uncommon, corpus cavernosograms are made by direct injection of suitable contrast material into the corpora cavernosa of the penis. They can be useful in examining for Peyronie's disease or fibrosis, impotence, priapism, and traumatic penile...
Chapter 66. Dermal Hypertrophies and Benign Fibroblastic/Myofibroblastic Tumors > Peyronie Disease (Penile Fibromatosis) Fitzpatrick's Dermatology in General Medicine, 8e... Fibrosis of the dorso-lateral penis, resulting in curvature of the penis and erectile dysfunction, is termed Peyronie disease. Risk factors include genetic predisposition, trauma to the penis, smoking, alcohol consumption, and history of diabetes or hypercholesterolemia. 99 , 100 Over several...
Chapter 73. The Aging Face: Rhytidectomy, Browlift, Midface Lift > History of Facelift Techniques CURRENT Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 3e... to make patients look “over-pulled” and unnatural look. In the 1970s, facelift techniques changed dramatically with the description of the SMAS layer by Mitz and Peyronie. Skoog is credited with the development of SMAS manipulation. This began an era of different strategies to attain optimal vector pull...
Chapter 9. Hand Surgery > Dupuytren Disease Current Diagnosis & Treatment in Orthopedics, 5e.... Ectopic deposits may occur in the dorsum of the proximal interphalangeal joint (knuckle pads), the dorsum of the penis (Peyronie disease), and the plantar fascia of the foot (Ledderhose disease). ...
Complications of Urologic Procedures and Devices > COMPLICATIONS OF DEVICES FOR ERECTILE DYSFUNCTION Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e... The most common causes of erectile dysfunction are diabetes, priapism, vascular disease, Peyronie's disease (deformity especially seen on erection due to nodules/fibrous plaques in penile tissue), pelvic trauma or surgery, spinal cord injury, and psychogenic reasons. Although oral medication...
Endocrine Tumors of the Gastrointestinal Tract and Pancreas > Clinical Features Harrison's Principles of Internal Medicine... wheezing or asthma-like symptoms (8–18%), pellagra-like skin lesions (2–25%), and impaired cognitive function. A variety of noncardiac problems due to increased fibrous tissue have been reported, including retroperitoneal fibrosis causing urethral obstruction, Peyronie’s disease of the penis...
Endocrine Tumors of the Gastrointestinal Tract and Pancreas > Pathobiology Harrison's Principles of Internal Medicine... release could be involved in mediating either the diarrhea or flush, but conflicting data exist. Both histamine and serotonin may be responsible for the wheezing as well as the fibrotic reactions involving the heart, causing Peyronie’s disease and intraabdominal fibrosis. The exact mechanism...
Male Genital Problems > PEYRONIE'S DISEASE Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e... Peyronie's disease produces progressive penile deformity, typically curvature with erections, that is painful and may result in erectile dysfunction or preclude successful vaginal penetration during intercourse. 26 Examination of the penile shaft will disclose a thickened plaque, typically...
Sports Medicine & Outpatient Orthopedics > General Considerations Current Medical Diagnosis & Treatment 2016..., particularly in those of Celtic descent. The incidence is higher among alcoholic patients and those with chronic systemic disorders (especially cirrhosis). It is also associated with systemic fibrosing syndrome, which includes plantar fibromatosis (10% of patients), Peyronie disease (1–2%), mediastinal...
The Male Genitalia and Reproductive System > Plastic induration of the penis (Peyronie disease) DeGowin’s Diagnostic Examination, 10e
The Spine, Pelvis, and Extremities > Contracture of the plantar fascia DeGowin’s Diagnostic Examination, 10e... Unilateral or bilateral asymptomatic thickening of the plantar fascia is associated with Dupuytren contracture of the palms and Peyronie syndrome. ...
Urologic Disorders > 5. Penile painCurrent Medical Diagnosis & Treatment 2016.... Pain in the erect penis may be due to Peyronie disease (fibrous plaque of the tunica albuginea, resulting in painful curvature of the erect penis) or to priapism (prolonged erection). ...
Urologic Disorders > F. Medical and Surgical Therapy for Peyronie Disease Current Medical Diagnosis & Treatment 2016... A wide range of medical and surgical treatments have been used to treat the disorder. Clostridial collagenase is the only FDA-approved medication for the treatment of Peyronie disease. Collagenase is administered to the central portion of the penile plaque by needle injection; it causes...
Urologic Disorders > General Considerations Current Medical Diagnosis & Treatment 2016.... Peyronie disease is a fibrotic disorder of the tunica albuginea of the penis resulting in varying degrees of penile curvature or deformity. Peyronie disease develops in approximately 5–10% of men older than 50 years. While 10% of men improve spontaneously, 50% will stabilize and the remainder...
Urologic Disorders > MALE ERECTILE DYSFUNCTION & SEXUAL DYSFUNCTION Current Medical Diagnosis & Treatment 2016... ESSENTIALS OF DIAGNOSIS Erectile dysfunction can have organic and psychogenic etiologies, and the two frequently overlap. Organic erectile dysfunction may be an early sign of cardiovascular disease and requires evaluation. Peyronie disease is a common, benign fibrotic disorder...
Urologic Disorders > When to Refer Current Medical Diagnosis & Treatment 2016... Patients with inadequate response to oral medications, who are unable to tolerate side effects or who are dissatisfied with their current treatment. Patients with Peyronie disease or other penile deformity. Patients with a history of pelvic or perineal trauma, surgery, or radiation...
Urology > PEYRONIE’S DISEASE CURRENT Diagnosis & Treatment: Surgery, 14e.... If the patient is impotent, insertion of a penile prosthesis is the procedure of choice. Fibrosis of the dorsal covering sheaths of the corpora cavernosa occasionally occurs without known cause in men over age 45. Trauma to the penis during intercourse has been implicated in the etiology of Peyronie’s...