Contemporary Review of Peyronie’s Disease Treatment

Measurement of Oxidative Stress Index (OSI) in Penile Corpora Cavernosa and Peripheral Blood of Peyronie's Disease Patients: A Report of 49 Cases

Peyronie's disease (PD) is a chronic inflammatory disease affecting the penile albuginea. Oxidative stress (OS) is important for the development of the disease; therefore, it seemed interesting to us to directly measure OS at both the site of the disease and in peripheral blood. For a precise OS study, it is necessary to evaluate not only the single results of the total oxidant status (TOS) and total antioxidant status (TAS) but also their ratio: OS index (OSI) (arbitrary unit) = TOS/TAS × 100. This study included 49 PD patients examined and diagnosed in our Peyronie's care center and a control group of 50 cases. We collected blood samples from both the penis and a vein in the upper extremity; we used d-ROMs and PAT-test (FRAS kit) for OS measurement. Pearson's study found a statistical correlation between penile OSI values and PD plaque volumes: p-value = 0.002. No correlation was found between systemic OSI values and PD plaque volumes: p-value = 0.27. Penile OSI values were significantly reduced after the elimination of the PD plaque (p < 0.00001). The mean value of the penile OSI indices in the PD patients after plaque elimination corresponded to 0.090 ± 0.016 (p = 0.004). The comparison between the penile OSI values of the PD patients (with plaque elimination) and the control group revealed no statistically significant differences (p = 0.130). The absence of a correlation between Peyronie's plaque volume and systemic OSI values indicates that it is preferable to carry out the OS study by taking a sample directly from the site of the disease. By carrying out a penile OSI study, it would be possible to obtain a precise plaque-volume-dependent oxidative marker. Even if the study did not demonstrate any correlation between OSI indices and anxious-depressive state, we detected a high prevalence of anxiety (81.6%) and depression (59.1%) in PD patients.

Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis

ABSTRACT

Peyronie's disease (PD) is characterized by abnormal penile curvature, and various surgical methods have been developed using different graft materials. However, there is currently no universal agreement on which type of graft is the best. The objective of this review was to evaluate the available literature and identify the most effective graft material for penile curvature correction in PD. A literature search was conducted using electronic databases, including PubMed, Scopus, and the Cochrane Library. The patients, intervention, comparison, and outcome (PICO) approach was used to define the eligibility of studies. Two authors independently selected studies, evaluated them, and extracted data. Random-effect models using the DerSimonian-Laird method were used. Most studies were single-arm studies and had a high risk of bias. Buccal mucosa grafts (BMG) were found to result in the highest penile straightening rates and were associated with the least de novo erectile dysfunction. TachoSil grafts demonstrated a high success rate in straightening despite a higher mean preoperative curvature, while Tutoplast grafts had a higher incidence of postoperative erectile dysfunction. BMG had the highest percentage of postoperative penile straightening. Overall, the TachoSil graft showed the best performance when preoperative curvature is taken into account. Based on the available literature, BMG appear to be the most effective for penile curvature correction in PD, but this is offset by the requirement for low preoperative curvature. The TachoSil graft shows the best overall performance when preoperative curvature is considered. Comparative randomized clinical trials are still needed to determine graft superiority.

Predictors of hinge effect in patients with Peyronie's disease

BACKGROUND

Patients with Peyronie's disease present with a variety of penile deformities. Those with hinge effect can experience bothersome buckling of the erection and instability during penetrative sex; however, the actual characteristics and clinical implications are not fully understood.

AIM

To determine the factors that cause hinge effect and to assess the role on surgical intervention.

METHODS

This retrospective review included 1223 consecutive patients who were examined by a single surgeon and had a complete penile duplex evaluation with curvature and hinge assessment. Baseline demographics, penile duplex findings, and clinical outcomes were used to assess for predictors of hinge effect.

OUTCOMES

Analyses were performed to assess preoperative predictors of hinge effect and surgical intervention.

RESULTS

Hinge effect was observed at the time of penile duplex Doppler examination in 33% of patients. Circumferential girth discrepancy at point of indentation (odds ratio [OR] 1.82; P < .001), rigidity of erection (OR, 0.82; P = .002), and degree of primary curvature (OR, 1.03; P < .001) predicted the presence of hinge effect. When controlling for rigidity, a girth discrepancy >1 cm did appear to be associated with a hinge.

CLINICAL IMPLICATIONS

Circumferential girth discrepancy >1 cm, regardless of erectile rigidity, can be associated with hinge effect.

STRENGTHS AND LIMITATIONS

As a strength, this study included the largest cohort of patients with Peyronie's disease, all of whom were examined in a rigorous and uniform manner via the same operative counseling. However, the study is limited by its retrospective nature and potential for selection and observer bias, given that the treating physician was also assessing all penile deformities as well as performing operative intervention.

CONCLUSIONS

The presence of hinge effect can cause instability of erections during penetrative sex. Multiple factors may predispose patients to a hinge effect, including the quality of erection and severity of curvature. But when controlling for rigidity, a girth discrepancy >1 cm did appear to be associated with a hinge. While many factors, such as baseline erectile dysfunction and severity of curvature, are important in determining the optimal surgical intervention, assessing for preoperative hinge effect also influenced the surgical approach.

Molecular Mechanisms and Risk Factors Related to the Pathogenesis of Peyronie's Disease

Peyronie's disease (PD) is a benign condition caused by plaque formation on the tunica albuginea of the penis. It is associated with penile pain, curvature, and shortening, and contributes to erectile dysfunction, which worsens patient quality of life. In recent years, research into understanding of the detailed mechanisms and risk factors involved in the development of PD has been increasing. In this review, the pathological mechanisms and several closely related signaling pathways, including TGF-β, WNT/β-catenin, Hedgehog, YAP/TAZ, MAPK, ROCK, and PI3K/AKT, are described. Findings regarding cross-talk among these pathways are then discussed to elucidate the complicated cascade behind tunica albuginea fibrosis. Finally, various risk factors including the genes involved in the development of PD are presented and their association with the disease summarized. The purpose of this review is to provide a better understanding regarding the involvement of risk factors in the molecular mechanisms associated with PD pathogenesis, as well as to provide insight into disease prevention and novel therapeutic interventions.

Significant inverse association of testosterone level with penile deformity severity in Japanese males with Peyronie's disease

OBJECTIVES

We evaluated the relationship between penile curvature and testosterone in Peyronie's disease patients treated in Japan.

METHODS

Data were obtained from 109 patients with Peyronie's disease treated with surgery at our hospital between April 2004 and December 2019. Penile deformity assessment was based on findings of a rigid erection induced by intracavernosal injection. Low total testosterone level was defined as <300 ng/dl. Patients were divided into two groups according to curvature severity (I, <60°; II ≥60°), then clinical factors including total testosterone were compared. Uni- and multivariate logistic regression analyses were performed to identify factors predicting severe penile deformity (≥60°).

RESULTS

For all patients, mean total testosterone was 469 ng/dl and median curvature was 50°, with a significant inverse correlation found between curvature and testosterone level (p < 0.0001). Group I and II patients numbered 55 and 54, respectively. Mean total testosterone for Group II was 397 ng/dl, significantly lower than Group I (539 ng/dl). Median curvature in 15 patients with a low testosterone level was 80°, significantly higher than those with a normal testosterone range (50°). Univariable and multivariable logistic regression analysis indicated total testosterone, follicle stimulating hormone, and C-reactive protein as significant factors correlated with severe penile deformity, among which total testosterone was most relevant.

CONCLUSION

The present findings confirmed that penile deformity severity is correlated with testosterone level in Japanese males with Peyronie's disease.

The efficacy and safety of intralesional injection of collagenase Clostridium histolyticum for Peyronie’s disease: A meta-analysis of published prospective studies

Background: Peyronie’s disease (PD) is a progressive fibrotic disorder of the penis that is adverse to men’s health. Currently, effective and reliable non-surgical options for PD are limited. Since the Food and Drug Administration (FDA) approved it in 2013, intralesional injection of collagenase Clostridium histolyticum (CCH) became the only licensed treatment for PD. This meta-analysis aims to evaluate the clinical efficacy and safety of CCH in treating PD, predominantly based on post-FDA studies.

Methods: The primary outcome was clinical efficacy evaluated by the percentages of improvement in penile curvature (PC) and Peyronie’s disease symptom bother score (PD bother score). The secondary outcome was the safety assessed by treatment-related adverse events (TRAEs). Heterogeneity was assessed by Cochran’s Q and I2 tests. Sensitivity and subgroup analyses were performed to explore the source of heterogeneity. Funnel plots and Egger’s test were used to evaluate the publication bias.

Results: A total of 11 studies with 1,480 intentions to treat (ITT) population were included. The pooled effect of the improvement of PC was 35% (95% CI: 0.33–0.38), and the pooled improvement of the PD bother score was 41% (95% CI: 0.37–0.45). No heterogeneity was found at the pooled improvement of PC (p = 0.845, I2 = 0.00%). Meanwhile, some heterogeneity existed in the pooled improvement of the PD bother score (p = 0.069, I2 = 43.4%). The pooled effect of TRAEs was 93% (95% CI 0.88–0.97) with significant heterogeneity (p &lt; 0.000, I2 = 92.3%).

Conclusion: The intralesional injection of CCH could significantly improve the penile deformity of PD patients. Meanwhile, CCH appears to ameliorate the PD bother score to some extent and has acceptable clinical safety. Future studies are required to clarify the long-term outcomes of CCH injection in the treatment of PD.

Comparison of technical success and adverse events of plaque incision and grafting methods in patients with Peyronie's disease: Tunica vaginalis versus buccal mucosa

OBJECTIVE

To compare the clinical outcomes of Peyronie's disease (PD) patients who were treated by plaque incision and grafting either with tunica vaginalis (TV) or buccal mucosa (BM) grafts.

METHODS

PD patients in BM (n=20) and TV group (n=20) were recruited between 2013 and 2020. Erectile dysfunction was assessed by short form of International Index of Erectile Function Questionnaire (IIEF-5). Technical success was defined as residual curvature ≤15°. Penile Doppler ultrasound was performed at baseline evaluation, 3-, and 24 months. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistance index were measured in erect penis. Erect penile length and curvature angle were measured at baseline and at 3, 12, and 24 months.

RESULTS

Mean age of the groups was comparable (47.2±10.8 years in TV vs 46.5±9.9 years in BM groups). Baseline mean penile curvature was 48.0±6.6° (TV) and 50.3±11.6° (BM) (p<0.001). Mean residual curvature at 24-months visits was 12.4±4.9° (TV) and 7.9±3.7° (BM), not significantly different. Technical success rate was 90% for both groups at 24 months. Surgery significantly increased erect penile length in both groups. Mean preoperative IIEF-5 scores were 18.4±2.5 and 17.5±2.2 in TV and BM groups, respectively. In both groups, IIEF-5 scores significantly improved after surgery with no intergroup IIEF-5 difference (20.6±2.6 in TV and 21.3±2.2 in BM). Mean postoperative PSV significantly increased, EDV significantly decreased in both groups, however, there was no significant intergroup difference.

CONCLUSION

Both grafting materials provided similar beneficial effects regarding technical success, erectile dysfunction, and penile length.

Use of penile shear wave elastosonography for the diagnosis of Peyronie's Disease: a prospective case-control study

BACKGROUND

To evaluate the stiffness of the tunica albuginea (TA), we used a new noninvasive diagnostic technique called shear wave elastography (SWE). We determined whether SWE values are correlated with the degree of penile curvature, the time of disease onset, and pain severity experienced by patients during erection. This study analyzed the elasticity of the TA of patients with Peyronie's disease compared to that of the control group. We also analyzed any correlations between the stiffness of the cavernous bodies and the degree of curvature, time from diagnosis to curvature onset, and erectile pain severity. This was a prospective case-control study involving 100 men enrolled from September 2020 to August 2021. Participants were divided into group A (case group, n = 50), which included men with PD, with or without pain, and with penile curvature, or group B (control group, n = 50), which included healthy patients older than 18 years who visited the urology clinic for reasons other than PD. The medical history was collected for all patients who also underwent objective examination, B-mode ultrasound evaluation, and SWE. The International Index of Erectile Function (IIEF-15) visual analog scale (VAS) questionnaire was administered to all participants.

RESULTS

There were no significant between-group differences regarding age, weight, and height (p > 0.05); however, there was a significant difference in the stiffness values (p < 0.05). An inverse correlation was observed between stiffness and the VAS score (p < 0.0001). A positive correlation was observed between the degree of curvature (p < 0.0001) and the time of curvature onset (p < 0.0001). The IIEF-15 scores were poorer in group A than in group B (p < 0.0001).

CONCLUSION

SWE is an inexpensive, noninvasive method that can be used to measure the stiffness of PD patients.

Efficacy and Safety of Collagenase Clostridium Histolyticum in the Treatment of Peyronie's Disease: An Evidence-Based Analysis

Background

Peyronie's disease (PD) is a chronic wound healing disorder, mainly involving tunica albuginea. Collagenase Clostridium Histolyticum (CCH) has shown its effectiveness in treating PD, but its efficacy and safety remain controversial, which propelled us to conduct the first evidence-based research on this topic.

Methods

We searched the Web of Science, PubMed, Embase, and ClinicalTrials.gov for related randomized controlled trials (RCTs). A systematic review and meta-analysis were performed to compare the penile curvature deformity (PCD), Peyronie's Disease Questionnaire peyronie's disease symptom bother (PDSB), penile pain score, total treatment-related adverse events (TAEs), and specific adverse events, including penile pain, penile edema, injection site pain, and contusion. Cochrane Collaboration's tool and Review Manager 5.3.0 version were applied, respectively, to evaluate the study quality and heterogeneity.

Results

Four articles (five RCTs) with 1,227 patients were finally included in the meta-analysis. The results revealed that CCH had excellent efficacy in relieving PCD (weighted mean difference [WMD]: −318.77, p &lt; 0.001) and PDSB (WMD: −1.20, p &lt; 0.001) compared to the placebo group, but there was no difference in the penile pain score (WMD: −0.64, P = 0.39) between the two groups. Furthermore, the incidence of TAEs in the CCH group was higher [odds ratio (OR): 12.86, p &lt; 0.001].

Conclusions

The current evidence suggests that CCH has a significant effect on treating PD. Considering that all these adverse events are acceptable and curable, CCH could slow the disease progression in the acute phase or act as a substitute for patients unable or unwilling to undergo surgery. However, the conclusion could not be certainly drawn until RCTs with a larger scale proved it.

Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review

BACKGROUND

Congenital penile curvature (CPC) is corrected surgically by various corporoplasty or tunica albuginea plication techniques, but the optimal surgical approach is not well-defined.

AIM

To provide a comprehensive evaluation of the published literature pertaining to outcomes with penile plication and corporoplasty techniques for surgical management of CPC. To determine if plication or corporoplasty offers superior outcomes in surgical correction of CPC.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Checklist. The following databases were queried from inception to March 18, 2020 to search for studies describing surgical treatment of CPC: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.

OUTCOMES

Objective and subjective postoperative outcomes including penile straightening, shortening, penile sensory changes, and reoperation rates for both corporoplasty and tunica albuginea plication were summarized.

RESULTS

Fifty-five articles comprising 2,956 patients with CPC who underwent a plication procedure (n = 1,375) or corporoplasty (n = 1,580) were included. The definition of "treatment success" varied widely and most often involved subjective patient reporting (22 studies; 40%) or objective assessment (15 studies; 27%). We considered curvature correction to be satisfactory if there was self-reported patient satisfaction or residual curvature after correction of <20˚. Reported rates of successful straightening ranged from 75 to 100% and 73 to 100% for plication and corporoplasty, respectively. A comprehensive and accurate assessment of surgical outcomes for CPC correction, such as satisfactory penile straightening, reoperation rates, glans sensory changes, and other complications was limited by significant inter-study heterogeneity with respect to the reporting of treatment outcomes.

CLINICAL IMPLICATIONS

While both plication and corporoplasty appear to be safe and effective options in the treatment of CPC, definitive conclusions cannot be drawn with respect to treatment superiority due to low-quality study design, methodology flaws, and significant heterogeneity in reporting.

STRENGTH & LIMITATIONS

This report represents the most comprehensive review of CPC surgical management. However, there is a significant lack of standardization in the reporting of treatment outcomes for CPC, thereby limiting the reliability of the published data summarization encompassed by our review.

CONCLUSION

Both plication and corporoplasty demonstrate high success rates and relatively low complication rates in the treatment of CPC, albeit with low-level evidence available in most research publications. Robust comparison of the surgical techniques used to correct CPC is limited by significant variation in reporting methods used in the literature. C. J. Britton, F. A. Jefferson, B. L. Findlay, et al. Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review. J Sex Med 2022;19:364-376.

Effects of plication procedures in special cases of Peyronie's disease: a single-center retrospective study of 72 patients

General recommendations regarding surgical techniques are not always appropriate for all Peyronie's disease (PD) patients. Therefore, the purpose of this study was to investigate the effects of plication procedures in PD patients with severe penile curvature and the effects of early surgical correction in patients who no longer have progressive deformities. The clinical data from 72 patients who underwent plication procedures were analyzed in this study. Patients were divided into Groups A and B according to the curvature severity (≤60° or >60°) and Groups 1 and 2 according to the duration of disease stabilization (≥3 months or <3 months). At the 1-year follow-up, 90.0% (36/40) and 90.6% (29/32) patients reported complete penile straightening, and 60.0% (24/40) and 100.0% (32/32) patients reported penile shortening in Groups A and B, respectively. No curvature recurrence occurred in any patient, and no significant differences were observed in postoperative International Index of Erectile Function–Erectile Function domain (IIEF-EF), erectile pain, sensitivity, or suture knots on the penis whether such outcomes were grouped according to the curvature severity or the duration of stabilization. However, the duration from symptom onset to surgical management in Group 1 was significantly longer than that in Group 2 (mean ± standard deviation [s.d.]: 20.9 ± 2.0 months and 14.3 ± 1.2 months, respectively, P < 0.001). The present study showed that the plication procedures seemed to be an effective choice for the surgical treatment of PD patients with severe penile curvature. In addition, the early surgical treatment seemed to benefit those patients who already had no erectile pain and no longer exhibited progressive deformity.

ESSM Position Statement on Surgical Treatment of Peyronie's Disease

INTRODUCTION

Patients with Peyronie's disease may experience significat distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity and direction of the curvature, penile length and the quality of erectile function.

AIM

To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.

METHODS

MEDLINE, Google Scholar and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/excision and grafting in order to identify an ideal graft, has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In order to allow shared decision making, a patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.

CONCLUSIONS

Current European Society for Sexual Medicine recommendations cover several aspects of Peyronie's disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways. Osmonov D. et al., ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med 2022;10:100459.

Causal contributors to tissue stiffness and clinical relevance in urology

Mechanomedicine is an emerging field focused on characterizing mechanical changes in cells and tissues coupled with a specific disease. Understanding the mechanical cues that drive disease progression, and whether tissue stiffening can precede disease development, is crucial in order to define new mechanical biomarkers to improve and develop diagnostic and prognostic tools. Classically known stromal regulators, such as fibroblasts, and more recently acknowledged factors such as the microbiome and extracellular vesicles, play a crucial role in modifications to the stroma and extracellular matrix (ECM). These modifications ultimately lead to an alteration of the mechanical properties (stiffness) of the tissue, contributing to disease onset and progression. We describe here classic and emerging mediators of ECM remodeling, and discuss state-of-the-art studies characterizing mechanical fingerprints of urological diseases, showing a general trend between increased tissue stiffness and severity of disease. Finally, we point to the clinical potential of tissue stiffness as a diagnostic and prognostic factor in the urological field, as well as a possible target for new innovative drugs.

Effects of patients' understanding and choice of surgical types on postoperative outcomes of Peyronie's disease: a single-center retrospective study of 108 patients

Surgical correction can be considered for treating patients with a chronic phase of Peyronie's disease (PD) and persistent penile curvature. In clinical practice, some patients pay too much attention to surgical complications and refuse the recommended feasible surgical types. Meanwhile, they require operations according to their preferences. This study aimed to evaluate the effects of patients’ own choice of surgical type on postoperative satisfaction. This retrospective study analyzed data from 108 patients with PD who underwent surgical correction according to doctors’ recommendations or patients’ own demands. The objective and subjective surgical outcomes were assessed. Patients’ understanding of the disease was analyzed using a questionnaire survey. Objective measurements of surgical outcomes, including penile straightening, penile length, and sexual function, in patients who received the recommended surgery, were similar to those in patients who did not accept the recommended surgery. However, subjective evaluations, including erectile pain, discomfort because of nodules on the penis, and decreased sensitivity in the penis, were more obvious in patients who did not follow doctors’ recommendations. In addition, a questionnaire survey showed that understanding PD and the purpose of surgery of patients who did not follow doctors’ advice were inappropriate, as they did not conform to the principle of treatment. The present study showed that surgical correction seemed to be an objectively effective option in the management of patients in the stable chronic phase of PD. Low patient satisfaction might be related to patients’ lack of correct understanding of the disease and its treatment strategy as well as unrealistic expectations.

Intralesional low-dose methylprednisolone for the treatment of active phase Peyronie's disease: A single-centre, preliminary prospective non-randomised study

AIM

There are a few types of drugs that can be used in the active phase of Peyronie's disease. Methylprednisolone is a corticosteroid with a strong anti-inflammatory effect. In this study, we aimed to evaluate the effect of intralesional low-dose methylprednisolone treatment on patients in the active phase of Peyronie's disease.

PATIENTS AND METHODS

Forty-eight patients suffering from Peyronie's disease active phase symptoms were included in the study. Methylprednisolone was administered intralesionally for 8 weeks, once per week, at a dose of 40 mg. The injection was applied to the plaques, which causes maximum curvature. Patients were evaluated before and after treatment for plaque size, angle of curvature, and erectile dysfunction according to the International Index of Erectile Function-5 and Peyronie's Disease Questionnaire.

RESULTS

The mean age of the patients was 61.1 (43-78) years. The mean duration of the symptoms was 3.4 (0-9) months. The average plaque size before treatment was 13.6 mm (7.1-16.8) and after treatment, this value decreased to 10.8 mm (4.3-14.6) (P: .025). The average scores of Peyronie's Disease Questionnaire elements; symptom severity, penile pain, and bother/discomfort were 12.3, 19.1, and 6.2, respectively, before the treatment. These scores were decreased to 8.9, 9.6, and 4.4, respectively, after treatment. All subgroups of Peyronie's Disease Questionnaire scores were significantly improved after treatment (P: .001, P < .001, P: .045, respectively). No adverse events were observed during or after treatment.

CONCLUSION

In order to recover the symptoms and signs, new and easily accessible drugs are required for use in the acute period of Peyronie's disease. In this context, treatment with intralesional low-dose methylprednisolone in acute phase Peyronie's Disease is a promising and safe treatment option.

Implications of Calcification in Peyronie's Disease, A Review of the Literature

A common characteristic of Peyronie's Disease (PD) is plaque calcification, which is associated with decreased response to treatments and higher rates of surgical intervention. Despite its prevalence in the PD population, the literature on plaque calcification is limited. While the diagnosis of PD is mostly clinical, imaging modalities such as ultrasound can be used to identify plaque calcification. The proper identification of plaque calcification is crucial for guiding management and setting therapeutic expectations for patients with PD. Herein we discuss what is known about PD plaque calcification, including epidemiology, etiology, diagnosis, and management.

Intralesional Injection Therapy and Atypical Peyronie's Disease: A Systematic Review

INTRODUCTION

Peyronie's disease (PD) is an inflammatory disorder of the tunica albuginea causing fibrotic changes including abnormal penile curvature, pain, and erectile dysfunction. Approximately 10% of PD patients will have atypical features including ventral plaques, hourglass deformities, unilateral indentations, severely shortened penile length, and multiplanar curvatures. Currently, the only intralesional treatment approved by the United States Food and Drug Administration is considered off-label for atypical PD. Furthermore, treatment of atypical PD, especially ventral plaques, is met with hesitation, in part due to potential urethral injury.

OBJECTIVES

To systematically review the available literature for the safety and efficacy of intralesional injections for atypical PD.

METHODS

A thorough literature search of the PubMed database was performed on manuscripts published between 1982 and 2020. Keywords included atypical Peyronie's disease, ventral plaque, hourglass deformity, and injection.

RESULTS

15 articles met the criteria for evaluation. Overall, 1,357 patients with PD were treated with intralesional therapy, of which 250 patients were considered to have an atypical presentation. 162 (648%) of the patients were treated with intralesional collagenase Clostridium histolyticum, 49 (19.6%) with verapamil, 29 (11.6%) with interferon alfa-2b, 5 (2.0%) with hyaluronic acid, and another 5 (2.0%) with onabotulinumtoxinA. There was only 1 reported severe adverse event (penile fracture), which was surgically repaired. There were no reports of urethral injury.

CONCLUSION

Intralesional injection treatment may be a safe alternative option for atypical PD. There is a great need for future research to closely monitor the role of intralesional therapy in this cohort. Choi EJ, Xu P, El-Khatib FM, et al. Intralesional Injection Therapy and Atypical Peyronie's Disease: A Systematic Review. Sex Med Rev 2021;9:434-444.

The Natural History of Peyronie's Disease

Peyronie's disease (PD), a fibrotic disorder of the tunica albuginea fully described in 1793 by French physician Francois de la Peyronie, is characterized by pain, plaque formation, penile deformity, and ultimately sexual function decline. The epidemiological data on PD vary considerably across previous studies, with recent evidence reporting a prevalence of up to 9%. PD is generally divided into two different phases: active or acute and stable or chronic. Plaque formation generally occurs during the acute phase, while during chronic phase pain usually tends to complete resolution and penile deformity stabilizes. PD's pathophysiology is still subject of great discussion. Tunical mechanical stress and microvascular trauma are major contributory factors. However, better understanding of the molecular pathophysiology of this condition remains paramount towards an in-depth comprehension of the disorder and the development of newer and more effective disease-targeted interventions. In this review we provide a detailed overview of natural history of PD, specifically focusing on clinical manifestations and the underlying molecular regulation patterns.

Outcome analysis of patients with Peyronie's disease who elect for vacuum erection device therapy

INTRODUCTION

Peyronie's disease (PD) affects approximately 0.7-11% of men and has numerous proposed treatments. Invasive management options include surgical or injectable therapy, while penile traction therapy with vacuum erection device (VED) represents a non-invasive approach. Our objective is to assess outcomes for patients with PD who opt for non-invasive management.

METHODS

We performed a retrospective analysis for patients with PD who were followed for at least three months and opted for noninvasive therapy. All patients were instructed to initiate VED traction therapy for 10 minutes twice per day. Patients were assessed for degree of PD deformity and erectile function (Sexual Health Inventory for Men [SHIM] score) at initial and subsequent encounters.

RESULTS

Fifty-three patients met the inclusion criteria. The mean (standard deviation [SD]) age was 57 (12) years, and the mean (SD) duration of PD prior to assessment was 25 (15) months. The mean (SD) duration of followup was 14 (11) months. Among untreated patients who did not use a VED, nine showed improvement, 20 remained stable, and four had worsening curvature. The untreated group had a significant change in curvature, with a mean improvement (SD) of 3.6 (12)° (p=0.048). All 20 men who initiated VED traction therapy had an improvement in curvature with a significant mean (SD) improvement of 23 (16)° (p=2.6×10^-6). Changes in SHIM scores did vary significantly between groups. No complications were noted.

CONCLUSIONS

In patients who opt for non-invasive management of PD, VED traction therapy provides improved curvature resolution compared to those who do not use such a device. The limitations of this study include the retrospective nature and a small sample size at a single treatment center.

Negative Self-Perception and Self-Attitude of Sexuality Is a Risk Factor for Patient Dissatisfaction Following Penile Surgery with Small Intestinal Submucosa Grafting for the Treatment of Severe Peyronie's Disease

Objective: To assess patient satisfaction with surgical outcome, body related self-perceptions, self-attitudes of sexuality, and health related quality of life after penile surgery with small intestinal submucosa (SIS) grafting for the treatment of severe Peyronie’s disease (PD). Material and methods: This retrospective study included 82 patients, who were treated with SIS grafting for severe PD between 2009 and 2013 at the University Medical Center Hamburg-Eppendorf. Patients were asked to complete standardized questionnaires including the International Index of Erectile Function Erectile Function domain (IIEF-EF), Short-Form (SF)-8 Health Survey, and Frankfurt Body Concept Scale-Sexuality (FKKS-SEX). Results: Follow-up was available in 58 (69.9%) patients. SIS grafting resulted in subjective straightening of the penis in 53 (91.3%) patients. After a mean follow-up of 28.9 ± 16.5 months, 24 (41.4%) patients were satisfied or very satisfied with surgical outcome. Postoperatively, the mean FKKS-SEX was 23.5 ± 5.9. In total, 36 (62.1%), 18 (31%), and four (6.9%) patients had FKKS-SEX scores corresponding to positive, neutral, and negative self-perception and self-attitude of sexuality, respectively. The mean postoperative SF-8 was 15.2 ± 6.4. Compared to the mean for German controls, patients achieved lower mean scores in the domains social functioning (50.4 ± 7.1), mental health (49.5 ± 9.2), and emotional roles (48.5 ± 6.8). Subjective shortening of the penis (Odds ratio (OR): 2.0), negative body related self-perceptions, and self-attitudes of sexuality (OR: 3.6) as well as IIEF-EF score (OR: 0.9) were risk factors for patient dissatisfaction (p-values ≤ 0.02). Conclusion: A relevant number of patients is not satisfied with surgical outcome after SIS grafting for the treatment of severe PD. Subjective shortening of the penis, negative body related self-perceptions, and self-attitudes of sexuality as well as IIEF-EF score were risk factors for patient dissatisfaction.

Comparison of Patient's Satisfaction and Long-term Results of 2 Penile Plication Techniques: Lessons Learned From 387 Patients With Penile Curvature

OBJECTIVE

To compare the patient's satisfaction and long-term results of 2 penile plication procedures in patients with penile curvature.

METHODS

This retrospective study included 387 patients with congenital penile curvature (n = 260) and Peyronie's disease (n = 127) who underwent surgical correction of penile curvature with penile plication procedures. Of the patients, 202 underwent plication of tunica albuginea with the Lue's 16-dot technique, while 185 underwent highly superficial excision of tunica albuginea with the modified Nesbit corporoplasty. Surgical outcomes and patient's satisfaction were compared between the 2 techniques in all patients.

RESULTS

The mean duration of surgery was significantly shorter in the 16-dot plication technique (48.1 ± 7.5 minutes), compared with the modified Nesbit corporoplasty (63 ± 16.9 minutes) (P = .001). Complete penile straightening was achieved in 87.6% of the patients who underwent 16-dot plication technique and in 89.7% of the patients who underwent modified Nesbit plication, revealing no difference (P = .514). The rates of penile sensory loss (P = .001) and de-novo erectile dysfunction (P = .016) were significantly higher in the modified Nesbit corporoplasty than in the 16-dot plication technique, but rate of suture related complications was significantly higher in the 16-dot plication technique than in the modified Nesbit corporoplasty (P = .001). The patients with congenital penile curvature had significantly less ratio of postoperative penile length loss and de-novo erectile dysfunction than Peyronie's disease patients.

CONCLUSION

Overall, both surgical techniques have very high success and satisfaction rates with very low complication rates. However, the types of complications are significantly different between the 2 surgical procedures. Therefore, patients with penile curvature should be informed about outcomes of penile plication procedures, and surgical method should be preferred based on patient's preference and surgeon's experience.

The use of penile traction therapy in the management of Peyronie's disease: current evidence and future prospects

Peyronie's disease is a disorder of abnormal and dysregulated wound healing leading to scar formation in the tunica albuginea of the penis. Penile traction therapy has emerged as an attractive therapeutic option for men with Peyronie's disease in both the acute and chronic phases. Currently, clinical studies are limited by lack of randomization, small cohorts, and lack of patient compliance with therapy. Despite these shortcomings, studies have shown a potential benefit with minimal morbidity. Specifically, penile traction may help to preserve or increase penile length and reduce penile curvature when used as monotherapy or as adjuvant therapy for surgical and intralesional treatments. Further study is necessary to define patient characteristics that are predictive of improved outcomes, determine the duration of treatment needed for clinical effect, and improve patient compliance.