Systematic evidence-based analysis of plaque injection therapy for Peyronie's disease

Intralesional collagenase Clostridium histolyticum vs. verapamil injections in males with Peyronie's Disease: A prospective, matched-pair, non-blinded, randomised clinical study comparing clinical outcomes and patient satisfaction rates

PURPOSE

To compare clinical outcomes and patient satisfaction rates between intralesional verapamil (ILV) and collagenase Clostridium histolyticum (CCH) injections in males with Peyronie's disease (PD).

MATERIALS AND METHODS

Following ethics approval, PD patients were prospectively enrolled in this open-label non-blinded study. Patients were randomised to receive ILV or CCH injections with penile remodelling every fortnightly for 6 courses. Patient demographics, change in penile curvature, International Index of Erectile Function-15 and Peyronie's Disease Questionnaire (PDQ) scores as well as overall patient satisfaction and Patient Global Impression of Improvement (PGI-I) scores were recorded at pre-treatment and 6-, 12- and 24-month post-treatment.

RESULTS

A total of 50 males were recruited and divided into ILV (n=25) and CCH (n=25) groups. The mean changes in penile curvature were -16.8 (standard deviation [SD] 7.65) degrees in ILV and -28.2 (SD 11.5) degrees in CCH groups (p<0.01). Patients in the CCH group scored better than the ILV group on the PDQ psychosexual symptoms (-2.14 vs. -2.9; p<0.01) and symptom bother score (-3.88 vs. -4.16; p=0.08). Minor treatment-related adverse events were more common in the CCH group. The overall satisfaction rate on a 5-point scale was 4.1 in ILV and 4.5 in CCH groups, and there was no statistically significant difference in the PGI-I scores between the 2 groups (p=0.14).

CONCLUSIONS

CCH therapy is more effective than ILV to treat a carefully selected group of males with PD, with a reasonable safety profile and a higher high level of patient satisfaction rate in the short term.

A systematic review of ankle fracture-dislocations: Recent update and future prospects

Background

Ankle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.

Methods

The available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.

Results

A total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).

Conclusions

Collectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.

Global Perspective on the Management of Peyronie's Disease

Introduction

Peyronie's disease is the disease that results in an alteration in the curvature of the penis, which can lead to a shortening of length, pain in erection, or difficulties in penetration, thus leading the patient to psychological alterations due to loss of functionality such as aesthetic alteration. That is why there are several studies to define the best form of treatment, which currently continues to be the first choice surgical treatment.

Objective

We present the most recommended therapies for Peyronie's disease and suggest an algorithm as a guide to direct therapy.

Methods

We used the PubMed platform to review the literature related to Peyronie's disease. Various editorials were reviewed as well as original articles and reviews focusing on the various treatments as well as their indications and results.

Results

Peyronie's disease in which conservative or drug treatment does not have a response, surgical treatment with corporoplasty, penile prosthesis implantation or both may be indicated. Corporoplasty refers to both the plication of the tunica albuginea as well as the incision of the tunica with the placement of a graft. An accurate history should always be carried out to identify erectile dysfunction as well as to be able to guide you on the repercussions of the treatment. If refractory erectile dysfunction is present, placement of a penile prosthesis with or without further adjunctive straightening maneuvers is recommended. We reviewed the indications, advantages, disadvantages, and results of the available techniques, and proposed a surgical treatment algorithm.

Conclusion

Penile shortening procedures are usually indicated in curvatures <60°, in penises with adequate length. Partial excision/incision and grafting are indicated for curvatures >60°, hourglass or hinge deformities, and short penises, if the patient's erectile function is adequate. The presence of “borderline” erectile function and/or ventral curvature tilts the choice toward shortening procedures, and refractory erectile dysfunction is an indication for penile prosthesis placement. An accurate risk/benefit assessment of the individual patient as well as meticulous patient counseling are critically important.

Peyronie Disease as a Marker of Inflammation-Is There Hope on the Horizon?

Although the description of Peyronie disease, a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis, is attributed to François de la Peyronie, surgeon to Louis XV of France, there are reports previous to that time. Over the intervening 450 years, a variety of empiric treatments, varying in barbarity, have been proposed. The frequency of this condition and the etiology of the fibrosis are unknown. Quality of life for affected men and their partners is adversely impacted. In this review, the authors summarize the history of the discovery of this condition, review contemporary management approaches, and address the pathophysiology leading to the underlying disordered fibrosis. The potential immunomodulatory role of testosterone as well as inflammatory conditions and environmental stimuli that may provoke fibrosis are also considered. Peyronie disease may be part of a spectrum of fibrotic conditions, including Dupuytren contracture. Treatment strategies to date have focused on reversing fibrosis; work is needed to prevent fibrosis and to accurately document disease prevalence.

Molecular Mechanisms and Current Pharmacotherapy of Peyronie's Disease: A Review

Peyronie’s disease (PD) is a localized fibrotic lesion of the penis that has adverse effects on men’s health. In this review, we summarized the molecular mechanisms and pharmacotherapies of PD. A literature search was conducted using PubMed and Cochrane Library during 2001–2020. Although no oral or topical medication demonstrated efficacy in monotherapy of PD, several intralesional medications have yielded promising results. Currently, the effective strategy in management of PD should be combined modality therapy, including but not limited to pharmacotherapy, mechanical therapy, and psychotherapy. Meanwhile, basic research is still necessary to facilitate the development of novel and more reliable treatments. In future, more attention should be given simultaneously to epigenetic changes, inflammatory cytokines, the abnormal wound-healing process, and profibrotic and anti-fibrotic factors to provide more options for this refractory disease.

Role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in Peyronie's disease: a new diagnostic approach to predict the stage of the disease?

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been associated with multiple entities and several types of cancers. They can be assumed as markers of inflammatory imbalance. The objective of this study is to evaluate the NLR and PLR in Peyronie's disease (PD) and to establish a comparison of its values in the acute and chronic stages. We recruited patients with PD from March 2018 to March 2019. The patients enrolled underwent medical and sexual history as well as a physical examination. The values of blood count of each patient were collected both in the acute and chronic stages. Wilcoxon test was used to compare the acute and chronic stage ratios. Kruskal–Wallis test was carried out to evaluate the impact of treatments on the ratios. To identify cutoff values, we used sensibility and specificity tables and receiver operating characteristic (ROC) curves. A total of 120 patients were enrolled. Their mean age was 55.85 (range: 18–77) years and the mean penile curvature was 48.43° (range: 10°–100°). In the acute stage, the mean NLR was 2.35 and the mean PLR was 111.22. These ratios, in the chronic stage, were 1.57 and 100.00, respectively. Statistically significant differences between acute and stable stages for both indices were found (NLR: P < 0.0001; PLR: P = 0.0202). The optimal cutoff for classification in acute or stable stage was 2 for NLR and 102 for PLR. According to our results, with an ordinary blood count, we could have important indications regarding the disease stage of the patient, and consequently on the most appropriate type of therapy to choose.

Treatment of peyronie's disease with combination of clostridium histolyticum collagenase and penile traction therapy: a prospective, multicenter, single-arm study

The aim of this paper is to analyze our experience with intraplaque administration of collagenase from Clostridium Histolyticum (CCH) together with penile modeling for selected patients with Peyronie's disease (PD). We conducted a prospective, multicenter, single-arm study. Patients were included from October 2015 to August 2019. We carried out the I + E PROTOCOL (IMPRESS + extender). Each cycle involved administration of two injections of CCH separated 24-72 h, up to a maximum of four cycles. 24-48 h after injection patients underwent penile modeling maneuvers with the use of a PTD at home for at least 4 h a day. After each cycle, penile curvature was evaluated by the Kelami test. Mean pretreatment curvature was 57° (30-100). Eighty-seven patients underwent at least a single cycle and were eligible for analysis. Mean number of cycles administered was 2. Final average curvature after treatment, regardless of the number of cycles was 34°, with a mean reduction in curvature of -23.29° (-41%). Across the first three cycles we found statistically significant differences in the means in terms of the degrees of curvature after each cycle (p < 0.05), however this was not maintained in the fourth cycle. Statistical significance was also found when comparing the initial and final curvature after the complete treatment. We can conclude that treatment with CCH for PD is safe and effective. The concomitant use of CCH and PTT may limit the number of treatment cycles necessary to optimize outcomes when compared with CCH alone.

[Non-surgical management of Peyronie's disease: State of current knowledge]

BACKGROUND

Peyronie's disease is an inflammatory disorder of the penis, where scar tissue creates a plaque at the level of the albuginea, limits its extension, and leads to a bent and shorter penis during erections. There are no international standards for the evaluation and the treatment of the disease. The aim of this article is to review the current knowledge about the management of Peyronie's disease and to suggest an algorithm to help physicians evaluate and manage this condition.

MATERIAL AND METHODS

A literature review was conducted through PubMed database following PRISMA guidelines using the Mesh terms: Peyronie, disease, treatment and diagnosis. Results are presented in a descriptive manner.

RESULTS

Multiple treatment strategies have been proposed, but no conclusive randomized clinical trial is done to assess their efficacies. The oral treatment was shown to be more beneficial in the setting of a multi-modal approach to treat the acute phase. The non-steroidal anti-inflammatories and the potassium para-aminobenzoate are superior to the other molecules of oral therapy for pain management. Local treatment with topical verapamil, iontophoresis and intra-lesional injection of verapamil, interferon alfa-2b and collagenase clostridium histolyticum (CCH) revolutionized the management of the disease by the modification of the plaque size and angulation. Alternative treatments using extra-corporeal shock wave or traction devices are promising. Intra-lesional injection of CCH is the only therapy approved by the Food and Drug Administration for this condition after the stabilization of the disease. The channeling of the plaque before CCH injections is making better results than the initial protocol, concerning angulation improvement.

CONCLUSION

Multiple therapeutic strategies exist for the management of the Peyronie's disease, but they lack evidence based data. Further randomized clinical trials are needed to evaluate the current practices and to study more efficient treatments.

Non-invasive treatment in the management of Peyronie's disease

Peyronies disease (PD) is estimated to affect approximately 3-9% of men worldwide and maybe associated with pain, erectile dysfunction and penile deformity including shortening. The condition has significant debilitating effects on quality of life, self-esteem and psychological wellbeing in addition to sexual function. Surgical results add further to this by patients having dissatisfaction with various aspects of outcomes. Non-surgical management may allow patients to avoid the morbidities associated with surgery and still achieve improved functional and aesthetic outcomes. Several non-surgical options are currently being employed in the treatment of PD that may reduce or stabilize both objective measures (e.g. penile length and deformity) and subjective measures (including sexual function, pain and partner satisfaction). Nonsurgical management can allow patients to avoid the morbidities associated with surgery and still achieve improved functional and aesthetic outcomes. In this article we explore the current non-surgical management options for PD including oral, mechanical therapies, intralesional and topical treatments. We also briefly discuss future treatment options in the form of stem cell therapy.

2018 Canadian Urological Association guideline for Peyronie's disease and congenital penile curvature

Peyronie’s disease (PD) is a highly prevalent condition that affects the physical and psychosocial well-being and quality of life (QoL) for thousands of Canadian men. The specific etiology of PD remains poorly understood and there remains a paucity of randomized placebo-controlled trials evaluating treatment interventions.1-3 PD can be found in up to 8.9% of men, a remarkable increase in cited prevalence that is attributable to growing awareness (as historical data suggested a rate of less than 1%); the burden of disease is significant, and PD is often present in otherwise healthy men. The following guidelines were crafted by the committee with a full awareness of the limitations of the literature, and sought to provide actionable recommendations to guide PD care in the Canadian health system.

Collagenase Clostridium Histolyticum in the Treatment of Peyronie's Disease: Review of a Minimally Invasive Treatment Option

Peyronie's disease (PD) is an inflammatory disorder characterized by an abnormal collagen deposition in the tunica albuginea of the penis, leading to fibrous and non-compliant plaques that can impede normal erection. Although pharmacological treatments are available, only intralesional injection therapy and surgical reconstruction have demonstrated tangible clinical efficacy in the management of this condition. Intralesional injection of collagenase clostridium histolyticum (CCH) has come to the forefront of minimally invasive treatment of PD. In this review, the authors provide an update on the safety, efficacy, and indications for CCH. The efficacy of CCH will be assessed on the basis of improvement in the severity of penile fibrosis, curvature, and pain. Numerous well-designed clinical trials and post-approval studies involving more than 1,500 patients have consistently demonstrated the efficacy and tolerability of CCH in the treatment of PD. CCH significantly decreases penile curvature and plaque consistency, as well as improves quality of life. Post-approval studies continue to demonstrate the efficacy of CCH despite broader inclusion criteria for treatment, such as the case with acute phase disease and atypical plaque deformities (i.e., ventral plaques, hourglass narrowing). CCH continues to be the gold standard for non-surgical management of stable phase PD, in the absence of strong evidence supporting oral therapy agents and ongoing evaluation of extracorporeal shockwave therapy. However, recent studies are beginning to provide precedent for the use of CCH in the management of acute phase and atypical PD.

Collagenase Clostridium histolyticum in the Treatment of Peyronie's Disease-A Review of the Literature and a New Modified Protocol

INTRODUCTION

Peyronie's disease (PD) is a common condition that results in penile deformity, which makes sexual intercourse difficult or impossible, and causes psychological, emotional, and relationship difficulties for the man affected and his partner. Collagenase Clostridium histolyticum (CCH; Xiapex, Xiaflex) is the first licensed non-surgical treatment option for PD. The safety and efficacy have been demonstrated in two large phase III randomized controlled trials (IMPRESS I and IMPRESS II).

AIM

To review the safety and efficacy of CCH and to introduce a new shortened modified protocol for CCH that was developed by the authors to decrease the cost and duration of treatment.

METHODS

A review of the medical literature on CCH for inclusion in this review was obtained by searching the PubMed (from 1946) and Medline (from 1946) medical databases and from the screening of relevant bibliographies. The search terms Xiapex, Xiaflex, collagenase Clostridial histolyticum, and Peyronie's disease were used. Clinical trials in men with PD and scientific articles relating to pharmacologic data were included in the review. When possible, large, randomized, and well-designed trials were selected.

MAIN OUTCOME MEASURES

Changes in the angle of penile curvature and in the Peyronie's Disease Questionnaire domains.

RESULTS

The clinical trials demonstrate the safety and efficacy of CCH in the treatment of PD. The new modified protocol developed by the authors is as safe and effective as the protocol used in the clinical trials.

CONCLUSION

CCH is the first licensed non-surgical treatment for PD. Its safety and efficacy have been demonstrated in large well-designed clinical trials. The new shortened modified protocol decreases the cost and duration of the treatment without compromising the safety and efficacy of the drug. This alteration will allow more patients to benefit from CCH. Abdel Raheem A, Johnson M, Abdel-Raheem T, et al. Collagenase Clostridium histolyticum in the Treatment of Peyronie's Disease-A Review of the Literature and a New Modified Protocol. Sex Med Rev 2017;5:529-535.

Evidence-Based Management Guidelines on Peyronie's Disease

INTRODUCTION

Despite recent advances in our knowledge and treatment strategies in Peyronie's Disease (PD), much remained unknown about this disease.

AIM

To provide a clinical framework and key guideline statements to assist clinicians in an evidence-based management of PD.

METHODS

A systematic literature search was conducted to identify published literature relevant to PD. The search included all relevant articles published up to June 2015, including preclinical studies and published guidelines. References used in the text were assessed according to their level of evidence, and guideline recommendations were graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Owing to the paucity of larger series and randomized placebo-controlled trials with regard to surgical intervention, guideline statements are provided as clinical principle or expert opinion.

MAIN OUTCOME MEASURES

This literature was discussed at a panel meeting, and selected articles with the highest evidence available were used to create consensus guideline statements for the Fourth International Consultation on Sexual Medicine guidelines on PD.

RESULTS

In addition to existing Third International Consultation on Sexual Medicine guidelines on PD, seven new summary recommendations were created.

CONCLUSION

A greater understanding of the scientific basis of PD is greatly needed to address our understanding of the pathophysiology, clinical epidemiology, psychosocial, and diagnostic assessment as well as treatment strategies.

A review of the epidemiology and treatment of Peyronie's disease

Introduction

Peyronie’s disease (PD) has significant effect on patients and their partners. We provide a current review of the epidemiology as well as the nonsurgical and surgical treatment of PD.

Materials and methods

Review of literature pertaining to PD with focus on epidemiology and treatment options.

Conclusion

PD is common and likely underreported. The availability of new and highly effective treatment options will catalyze patient awareness and subsequently the prevalence of disease.

[Conservative therapy of Peyronie's disease - update 2015]

Peyronie's disease (PD) is a benign disease of the penis leading to development of fibrous plaques at the penile tunica albuginea. PD is a heterogeneous disease with variable constellation of symptoms (penile deviation, pain, penile shortening, erectile dysfunction). Due to lack of pathophysiological knowledge there is no causal therapy of PD. Surgical therapy still represents the gold standard for correction of penile deviation. Available conservative treatment options vary from oral medical therapy to minimally invasive treatments (e.g. iontophoresis) and invasive treatment modalities (e.g. intralesional therapy). A gold standard for the conservative therapy of PD does not exist due to the nonhomogeneous disease and the variable constellation of symptoms. New conservative treatment options like penile traction and also promising treatments like intralesional injection therapy with collagenase have to be further investigated and prove their efficacy in the long-term. Moreover, well-structured, standardized, randomized placebo-controlled studies have to be done for each of the treatment modalities, so that patients can be offered successful and evidence-based conservative therapies in the future.

Experience in the use of collagenase clostridium histolyticum in the management of Peyronie's disease: current data and future prospects

INTRODUCTION

Peyronie's disease (PD) is a chronic wound-healing disorder characterized by formation of fibrous inelastic scarring of the tunica albuginea resulting in a variety of penile deformities. In most cases, PD is accompanied by a physical and psychological impact. Xiaflex® is an injectable collagenase clostridium histolyticum (CCh) preparation consisting of a predetermined mixture of two distinct collagenases. Recently the US Food and Drug Administration (FDA) approved Xiaflex® for the nonsurgical treatment of men with PD with curvature of 30° or more and tangible scar tissue plaque in their penis.

METHOD

This article presents a comprehensive review of the updated information on the use of Xiaflex® for the nonsurgical treatment of PD.

RESULTS

Mean improvements in penile curvature ranging from 29% to 34% and in bother domain scores have been reported. The majority of the reported adverse effects are mild or moderate and 79% resolve without intervention.

CONCLUSION

The combined results of these trials have led to the FDA approval of CCh for the treatment of PD. However, the long-term effects and results need further investigation, with large follow-up series. Considering these results, future perspectives will probably result in the use of a combined or sequential therapy including CCh.

Clinical efficacy, safety and tolerability of collagenase clostridium histolyticum for the treatment of peyronie disease in 2 large double-blind, randomized, placebo controlled phase 3 studies

PURPOSE

IMPRESS (Investigation for Maximal Peyronie's Reduction Efficacy and Safety Studies) I and II examined the clinical efficacy and safety of collagenase Clostridium histolyticum intralesional injections in subjects with Peyronie disease. Co-primary outcomes in these identical phase 3 randomized, double-blind, placebo controlled studies included the percent change in the penile curvature abnormality and the change in the Peyronie disease questionnaire symptom bother score from baseline to 52 weeks.

MATERIALS AND METHODS

IMPRESS I and II examined collagenase C. histolyticum intralesional injections in 417 and 415 subjects, respectively, through a maximum of 4 treatment cycles, each separated by 6 weeks. Men received up to 8 injections of 0.58 mg collagenase C. histolyticum, that is 2 injections per cycle separated by approximately 24 to 72 hours with the second injection of each followed 24 to 72 hours later by penile plaque modeling. Men were stratified by baseline penile curvature (30 to 60 vs 61 to 90 degrees) and randomized to collagenase C. histolyticum or placebo 2:1 in favor of the former.

RESULTS

Post hoc meta-analysis of IMPRESS I and II data revealed that men treated with collagenase C. histolyticum showed a mean 34% improvement in penile curvature, representing a mean ± SD -17.0 ± 14.8 degree change per subject, compared with a mean 18.2% improvement in placebo treated men, representing a mean -9.3 ± 13.6 degree change per subject (p <0.0001). The mean change in Peyronie disease symptom bother score was significantly improved in treated men vs men on placebo (-2.8 ± 3.8 vs -1.8 ± 3.5, p = 0.0037). Three serious adverse events (corporeal rupture) were surgically repaired.

CONCLUSIONS

IMPRESS I and II support the clinical efficacy and safety of collagenase C. histolyticum for the physical and psychological aspects of Peyronie disease.

Phase 2b study of the clinical efficacy and safety of collagenase Clostridium histolyticum in patients with Peyronie disease

PURPOSE

Collagenase Clostridium histolyticum is an investigational nonsurgical treatment for Peyronie disease. In this phase 2b, double-blind, randomized, placebo controlled study we determined the safety and efficacy of collagenase C. histolyticum and assessed a patient reported outcome questionnaire.

MATERIALS AND METHODS

A total of 147 subjects were randomized into 4 groups to receive collagenase C. histolyticum or placebo (3:1) with or without penile plaque modeling (1:1). Per treatment cycle 2 injections of collagenase C. histolyticum (0.58 mg) were given 24 to 72 hours apart. Subjects received up to 3 cycles at 6-week intervals. When designated, investigator modeling was done 24 to 72 hours after the second injection of each cycle. We evaluated penile curvature by goniometer measurement, patient reported outcomes and adverse event profiles.

RESULTS

After collagenase C. histolyticum treatment significant improvements in penile curvature (29.7% vs 11.0%, p=0.001) and patient reported outcome symptom bother scores (p=0.05) were observed compared to placebo. In modeled subjects 32.4% improvement in penile curvature was observed in those on collagenase C. histolyticum compared to 2.5% worsening of curvature in those on placebo (p<0.001). Those treated with collagenase C. histolyticum who underwent modeling also showed improved Peyronie disease symptom bother scores (p=0.004). In subjects without modeling there were minimal differences between the active and placebo cohorts. Most adverse events in the collagenase C. histolyticum group occurred at the injection site and were mild or moderate in severity. No treatment related serious adverse events were reported.

CONCLUSIONS

Collagenase C. histolyticum treatment was well tolerated. We noted significant improvement in penile curvature and patient reported outcome symptom bother scores, suggesting that this may be a safe, nonsurgical alternative for Peyronie disease.

Current status and new developments in Peyronie's disease: medical, minimally invasive and surgical treatment options

INTRODUCTION

Peyronie's disease (PD) is a wound-healing disorder of the tunica albuginea of the penis which affects 3-9% of adult males. Clinically, any combination of plaque formation, penile pain, angulation and erectile dysfunction may appear. This condition may progress, stabilize or, uncommonly, regress during the initial acute phase (6-18 months).

AREAS COVERED

Information regarding this review was searched in PubMed until August 2010. Vitamin E, paraaminobenzoate and colchicine are sparingly employed oral medical therapies. Intralesional injections as a minimally invasive therapy for PD includes injection with verapamil, interferon-α-2b, and collagenase. Men suffering with PD who have significant penile deformity precluding successful coitus can be appraised for surgical correction. Surgery is considered the gold standard and includes plication, incision and grafting- or penile-prosthesis-related procedures.

EXPERT OPINION

This paper provides a broad overview of the subject of PD, available nonsurgical options and surgical approaches that will aid in the routine clinical diagnosis and management of PD. Increased public and medical awareness of PD prevalence, presentation, diagnosis and treatment options will serve well the large population of men who suffer in silence with this common condition.

The role of vacuum pump therapy to mechanically straighten the penis in Peyronie's disease

OBJECTIVE

to assess the efficacy of vacuum therapy in mechanically straightening the penile curvature of Peyronie's disease (PD).

PATIENTS AND METHODS

Modelling of the tunica albuginea has been shown to be possible during penile implant surgery and this principle has been applied as an alternative conservative therapy. In all, 31 patients with PD (mean duration 9.9 months; mean age 51 years, range 24-71) completed the study. Over a 12-week period, the patients used a vacuum device (Osbon ErecAid, MediPlus, High Wycombe, UK) for 10 min twice daily. The assessment at study entry and at completion after 12 weeks included the International Index of Erectile Function questionnaire, a perceived pain intensity score, stretched penile length measurement and the angle of penile deformity after an intracavernous injection with prostaglandin E1.

RESULTS

there was a clinically and statistically significant improvement in penile length, angle of curvature and pain after 12 weeks of using the vacuum pump. Of the 31 patients, 21 had a reduction in the angle of curvature by 5-25 degrees, three had worsening of the curvature and there was no change in the remaining seven. The curvature was corrected surgically in 15 patients while the remaining 16 (51%) were satisfied with the outcome.

CONCLUSION

vacuum therapy can improve or stabilize the curvature of PD, is safe to use in all stages of the disease, and might reduce the number of patients going on to surgery.

Penile traction therapy for treatment of Peyronie's disease: a single-center pilot study

INTRODUCTION

Peyronie's disease (PD) is a fibrotic disorder of the penis whose etiopathophysiology remains unclear. At this time, there is no known reliable nonsurgical treatment. This study reviews our experience with external penile traction therapy to correct the deformity associated with this disorder.

AIM

To evaluate prolonged external penile traction as a nonsurgical treatment for PD.

METHODS

Ten men with PD completed this noncontrolled pilot study of traction therapy using the FastSize Penile Extender. Nearly all (90%) had failed prior medical therapy. Traction was applied as the only treatment for 2-8 hours/day for 6 months. All subjects underwent pre- and post-treatment physical examination including measurement of stretched flaccid penile length (SPL) and biothesiometry.

MAIN OUTCOME MEASURES

Curvature and girth were measured during erection before and after treatment with dynamic duplex ultrasound. Assessment of erectile and sexual function was further assessed with the International Index of Erectile Function and Quality of Life Specific to Male Erection Difficulties (QOL-MED) questionnaires. At 3 and 6 months post-treatment, SPL was measured and subjective assessment of deformity by the patient was recorded.

RESULTS

Subjectively all men noted reduced curvature estimated at 10-40 degrees, increased penile length (1-2.5 cm) and enhanced girth in areas of indentation or narrowing. Objective measures demonstrated reduced curvature in all men from 10-45 degrees; average reduction for the group was 33% (51-34 degrees). SPL increased 0.5-2.0 cm and erect girth increased 0.5-1.0 cm with correction of hinge effect in four out of four men. International Index of Erectile Function-erectile function domain increased from 18.3-23.6 for the group. Changes in quality of life by QOL-MED were not found to be statistically significant in this small series. There were no adverse events including skin changes, ulcerations, hypoesthesia or diminished rigidity.

CONCLUSION

Prolonged daily external penile traction therapy is a new approach for the nonsurgical treatment of PD. Further study appears warranted given the response noted in this pilot study.

‘Off-label’ drug use in sexual medicine treatment

Phosphodiesterase type 5 inhibitors are the only drugs approved for a specific sexual function disorder. All other drugs used in the treatment of sexual disorders are used 'off-label.' This paper reviews the use of drugs in the treatment of premature ejaculation, Peyronie's disease and female hypoactive sexual desire disorder (HSDD). While the treatment of premature ejaculation is quite well documented and supported by evidence of good quality in the medical literature, there is little evidence for the use of the variety of medications in use for the treatment of Peyronie's disease. In particular, the use of verapamil is not supported by any double-blind studies whatsoever. The use of testosterone patch for treatment of HSDD in postmenopausal women is well documented, but not in premenopausal women.