Current Strategies in the Management of Peyronie’s Disease (PD)—Results of a Survey of 401 Sexual Medicine Experts Across Europe

Penile prosthesis implantation is safe and effective in Peyronie's disease patients with and without erectile dysfunction

Penile prosthesis (PP) is the mainstay of treatment in Peyronie's disease (PD) with co-existent refractory erectile dysfunction (ED). This study aimed to assess the clinical outcomes of patients who underwent PP as the first-line surgical treatment in PD without ED. A total of 636 patients underwent PP for PD from 2012 to 2022, but only 168 patients who underwent PP as first-line surgical management for PD with or without ED were included in the study. The mean (SD) age of 168 patients was 56.3 years (12.4). The mean curvature of the "PD with ED" group and the "PD without ED" group were 38.2 (5.6) degrees and 42.2 (5.9) degrees. The median (IQR) follow-up was 56.0 months (34.5- 61.4). Most (86.9%) patients underwent 3-piece inflatable PP. An important finding is that 33 patients (19.6%) without ED had undergone PP. Mechanical failure requiring revision surgery was less common in the 'without ED' group than in the ED group (6.8% vs. 10.2%, p 0.04). Most PD patients without ED (87.9%, 29/33) and with ED (88.9%, 120/135) were "satisfied" after PP implantation at six months, as defined by a score of ≥4 on a 5-point Likert scale. If surgery is offered in PD, PP may be considered a safe and effective first-line surgical treatment regardless of the ED, given the acceptable complications and high satisfaction rates. However, this new concept warrants further research.

Daily low-dose tadalafil may reduce the penile curvature progression rate in patients with acute Peyronie's disease: a retrospective comparative analysis

The aim of this study was to evaluate the clinical outcomes of patients in acute phase of Peyronie's disease (PD) treated with daily low-dose of Tadalafil. An observational retrospective study involving patients in acute phase of PD with erectile dysfunction (ED) was designed. All subjects were offered Tadalafil 5 mg one tablet a day. Men who accepted treatment were compared to patients who refused Tadalafil. Penile curvature progression was chosen as the primary outcome. PD Questionnaire (PDQ) and IIEF-5 scores were selected as secondary outcomes. A total of 191 patients were included in the study (108 intervention vs. 83 control). Penile curvature progression rate was significantly lower in subjects taking Tadalafil at 12 weeks (25.9% vs. 39.7%, p = 0.042). Mean IIEF-5 score improved in the intervention group, becoming significantly higher compared to the observation group at 12 weeks (19.3 vs. 11.2 points, p < 0.001). Mean PDQ-Overall and PDQ-Penile Pain scores only improved in the intervention group and the statistically significant differences at baseline between groups became not statistically significant at 12 weeks (p = 0.001 vs. p = 0.232 and p < 0.001 vs. p = 0.078, respectively). Daily low-dose Tadalafil in patients with acute phase of PD seems to significantly reduce the penile curvature progression rate compared to observation, especially when it is administrated early. It also appears to improve erectile function and PD-related symptoms.

Current trends in non-surgical management of Peyronie's disease-A narrative review

Peyronie's disease (PD) is a connective tissue disorder affecting the tunica albuginea. It can cause pain and penile deformation, and its prevalence increases with age. Although surgery is the gold standard for the chronic phase of the disease, there are several conservative treatment methods available, and the optimal management of the acute phase of the disease remains a matter of debate. In this article, we aim to summarize the recent trends in research on the subject of non-surgical treatment of PD. The search was performed in PubMed, Scopus, and Web of Science databases and included studies in English published between 2012 and 2022 investigating the clinical outcomes of non-surgical PD management in humans. We have identified 20 distinct conservative treatment strategies. Among the oral therapeutics, only the use of phosphodiesterase type 5 inhibitors is currently recommended for clinical use in patients with concomitant erectile dysfunction. The use of collagenase from Clostridium histolyticum is supported by the best quality evidence in terms of intralesional injections for patients suffering from significant penile curvature; however, interferon alpha-2b can also be an option in such patients. Among other non-invasive methods, extracorporeal shockwaves can be useful for pain reduction, and penile traction therapy can lead to a reduction in penile curvature and plaque size. Despite a wide range of non-surgical methods available for PD treatment, the majority are not supported by sufficient scientific evidence, and the treatment efficacy is underwhelming. Further research on the subject of non-surgical management of PD is highly warranted.

Congenital penile curvature as a possible risk factor for the onset of Peyronie's disease, and psychological consequences of penile curvature

OBJECTIVE

To investigate a possible relationship between a history of congenital penile curvature (CPC) and Peyronie's disease (PD), and to characterize the psychological profile of patients suffering from PD, with or without concomitant CPC.

METHODS

We included 519 patients with Peyronie's disease (PD), of which 73 were found to have underlaying CPC. As a comparator population, we selected 2166 patients without PD, referring to our tertiary care clinic. In this population we detected 15 subjects with CPC. All patients completed the GAD-7 (Generalized-Anxiety-Disorder - 7 questions) and the PHQ-9 (Patient-Health-Questionnaire - 9 questions) questionnaires.

RESULTS

The overall prevalence of CPC in PD-patients was 14.07%, compared to a prevalence of 0.69% in the non-PD control population (p < 0.00001). Moderate-to-severe anxiety was found to be present in 89.4% of all PD-patients. Significantly higher proportions of patients with CPC associated with PD showed severe anxiety, compared to patients with PD alone (57.5% vs. 36.7%, respectively, p = 0.0008). Moderate- severe depression was found to be present in 57.8% of all PD- patients. Significantly higher proportions of PD patients with a history of CPC showed severe depression, compared to patients with PD alone (13.6% vs. 3.36%, respectively, p < 0.0002). GAD-7 median scores were significantly higher in patients with more severe penile curvatures (> 45°; p = 0.029). We did not detect a statistically significant difference between PHQ-9 medi- an scores based on the severity of PD (p = 0.53). Analysis of PHQ-9 and GAD-7 median scores showed significantly worse depressive and anxious symptoms in younger patients (p < 0.001 and p = 0.0013, respectively).

CONCLUSIONS

The presence of congenital-penile-curvature may represent a risk factor for the subsequent onset of Peyronie's disease. Moderate/severe anxiety and moderate/severe depression were reported in a high fraction of cases. Anxiety was significantly higher in patients with more severe penile-curvatures, and depression was present independently of the degree of penile curvature. Depression and anxiety were found to be more severe in younger subjects.

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.

Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease

INTRODUCTION

Across many cultures, penis size has been associated with virility, and concerns about penile length are commonplace. Peyronie's disease (PD) is a known acquired cause of penile shortening.

OBJECTIVES

This paper describes the psychosocial impacts of penile length on men and their partners, both generally and in men with PD, and evaluates the effect of PD treatments (eg, collagenase clostridium histolyticum , surgery, mechanical therapy) on this outcome measure.

METHODS

A PubMed database search was performed for English language articles through July 2021. Main outcome measures were association of penile length with emotional well-being, selfesteem, and relationship satisfaction in men with PD, and change from baseline penile length after treatment.

RESULTS

Shortened penile length caused by PD can negatively impact patient and partner quality of life, including effects on body image, emotional well-being, sexual function, and interpersonal relationships. In men with PD, studies have demonstrated an association between loss of penile length and emotional problems, reduced satisfaction with sexual performance, poor self-esteem, depression, and relationship difficulties. Loss of penile length can frequently occur after surgery for PD (including plication, plaque incision/excision with grafting, and penile implant). Advanced surgical techniques may preserve/increase penile length, but the increased risks associated with these complex procedures must be carefully considered. Treatment with collagenase clostridium histolyticum does not appear to negatively impact penile length, and 5-year follow-up data suggest potential longterm posttreatment improvements in this outcome measure. Penile traction therapy, either alone or as adjunctive therapy, may increase penile length in men with PD, but nonadherence may limit improvement.

CONCLUSION

Changes in penile length are important to many men, particularly those with PD, and should be considered during PD treatment selection. Penile length should be measured objectively before and after treatment for PD and should be included as an outcome measure in future studies on treatment effectiveness. Goldstein I, Gelbard MK, Lipshultz LI. Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease. Sex Med Rev 2022;10:409-420.

Trends in treatment of Peyronie's disease in adult men in the United States from 2008 to 2017-results from an encounter and claims database

Treatments for Peyronie's Disease (PD) include oral medications, intralesional injections, and surgery. Collagenase Clostridium histolyticum (CCh) is the only FDA-approved treatment for PD. We sought to examine current trends in treatment of PD across the United States. Using data in the MarketScan Database, we conducted a retrospective study of men with PD in the United States. Cases were identified by ICD-9 and 10 codes, and treatments were identified using NDC and CPT codes. Treatment rates were analyzed using a linear regression model, and a Cox proportional hazard function test was performed for time-to-treatment analysis. About 27.8% of men with PD were treated within a year of diagnosis. The annual treatment rate increased from 23.2 to 35.4%, and intralesional injection was the most used treatment. Over the study period, the percentage of men receiving treatment with oral medication increased from 0.66 to 20.5%, while the use of intralesional injection and surgery decreased. Increased odds of treatment were observed in men 45-54 years (odds ratio [OR] 1.35; 95% confidence interval [CI], 1.21-1.50; p = 0) and in the southern region (OR 1.48; 95% CI, 1.39-1.56; p = 0). Trends in treatment of PD have changed over time. Intralesional injection remains the most used treatment option for men with PD.

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.

Conservative Therapy for Peyronie's Disease: a Contemporary Review of the Literature

PURPOSE OF REVIEW

To analyze the literature on current conservative treatment options for Peyronie's disease (PD).

RECENT FINDINGS

Conservative therapy with intralesional collagenase clostridium histolyticum (CCH) is safe and efficacious in either the acute or chronic phases of PD. Combination treatment with penile traction therapy (PTT) can produce even better results. While most PTT devices require extended periods of therapy up to 8 h per day, the RestoreX® device can be effective at 30-90 min per day. A variety of conservative therapies are available for treatment of PD. The available literature does not reveal any treatment benefit of oral therapies. Intralesional therapy is the mainstay conservative treatment of PD. Intralesional CCH therapy is the first Food and Drug Administration-approved intralesional therapy and represents the authors' preference for medical therapy. The most effective conservative management of PD likely requires a combination of therapies.

Intralesional injection of the calcium channel blocker Verapamil in Peyronie's disease: A critical review

OBJECTIVE

To assess the effectiveness of an intralesional injection of verapamil in men with Peyronie's disease (PD).

MATERIALS AND METHODS

The data provided in the current review are based on a thorough review of the available original articles on PD retrieved with a systematic literature search using PubMed- Medline, and the Cochrane Central Register of Controlled Trials, up to December 2019, to identify studies dealing with Peyronie's disease and its treatment. Included were only original articles, that we thoroughly evaluated. We searched for the primary and secondary terms of: "Peyronie's disease," "Penile curvature," "Erectile dysfunction," "Verapamil and Peyronie's disease," "Calcium channel blocker," and "Intralesional injection."

RESULTS

The initial search of the databases yielded a total of 1240 studies (PubMed: 1058; Cochrane: 182), as of December 2019. Seventy studies were removed due to duplication. Further 986 studies were removed due to not being in English (except for one study by Arena F. for which we got a translation form Italian), being about animal experimentations, not being full-text, and not being clinical trials. Likewise, studies not referring at all to verapamil were excluded (148). From the remaining 36 full-text articles we focused on 13 studies which met the inclusion criteria, mainly being deemed relevant to the context of this study.

CONCLUSIONS

Calcium channel blockers have been shown in both in vitro and in vivo studies to inhibit the synthesis and secretion of extracellular matrix molecules, as well as to increase collagenase activity. Patients with localised plaque are the best candidates for intralesional injections of verapamil. The beneficial effects of intralesional verapamil are apparent within the first three months. For patients who respond to treatment, the injections should be continued for six months. Patients who fail to respond to intralesional verapamil or whose angulation is greater than 30° at presentation should be considered candidates for surgery. Injection of verapamil is clinically safe for patients with Peyronie's disease, and it appears to induce a rapid, beneficial effect in patients for the reduction of plaque size. Intralesional verapamil injection for Peyronie's disease could reduce pain, decrease penile curvature, and improve sexual function.

Low-intensity extracorporeal shockwave therapy among urologist practitioners: how the opinion of urologists changed between 2016 and 2019

Over the past few years, an increase use of low-intensity shockwave therapy (LISWT) for the treatment of erectile dysfunction (ED) has been observed. However, many controversies in the scientific literature about its efficacy still exist. We aimed to investigate changes in the pattern of usage and attitudes toward LISWT for ED among experts over the last years. A dedicated online survey was sent to delegates at the Congress for the EAU Section of Andrological Urology (ESAU) in Prague from 31st October to 1st November 2019. The survey captured demographic data, professional background, and the experience and personal knowledge about LISWT. The results were compared with a previous survey conducted in 2016 and investigating the same topics in order to assess changes in the knowledge and opinion on LISWT over time. Overall, 172 and 192 questionnaires were available from 2019 and 2016, respectively. Participants in the 2019 survey were 80 (45.7%) urologists, 52 (29.7%) uro-andrologists, and 34 (19.4%) residents in urology, from 30 different countries. Compared to the past, we observed an increase of respondents who were familiar with LISWT (75 vs. 95%; p < 0.0001) and who performed LISWT in their routine practice (38% in 2019 vs. 14% in 2016; p < 0.0001). Conversely, no changes in terms of overall perception of treatment efficacy were registered over time (68% in 2019 vs. 72% in 2016 considered LISWT as an effective treatment, respectively (p = 0.5)). An increased proportion of physicians had suggested a wider application of LISWT, and some even advocated its use in nonvasculogenic ED (33% in 2019 vs. 5.9% in 2016; p < 0.0001). The awareness and clinical application of LISWT for ED have increased over time, despite the lack of robust evidence in terms of effectiveness. Further research on the benefit of LISWT is needed to guide physicians in the therapeutic management of ED patients.

Peyronie's disease: Contemporary evaluation and management

Peyronie's disease is a common yet poorly understood condition characterized by penile pain, curvature, sexual dysfunction and psychological bother. Peyronie's disease represents a penile wound healing disorder, and is thought to arise from exuberant scarring in response to penile trauma in genetically predisposed men. In the absence of active treatment, the majority of men experience stable or worsening symptoms, with few reporting spontaneous resolution in penile curvature or other deformity. In contrast, penile pain improves or resolves in the majority of men. Treatment options vary based on symptom severity and stability. Several oral therapies are commonly prescribed, although to date there are no strong data to support any oral agents as monotherapy for Peyronie's disease. Other options including penile traction therapy and intralesional injections result in modest improvements for many patients, particularly when used early after symptom onset. Penile straightening through approaches, such as penile plication and plaque incision or partial excision and grafting, represent the most rapid and reliable approach to correct penile curvature once the symptoms have stabilized. Side-effects vary based on the type of surgery carried out, and include penile shortening, sensation changes and erectile dysfunction in the minority of men. In patients with drug refractory erectile dysfunction and Peyronie's disease, placement of a penile prosthesis will address both issues, and is associated with high levels of patient satisfaction. The current review provides a practical approach to the modern evaluation and management of patients presenting with Peyronie's disease.

Medical Management of Peyronie's Disease: Review of the Clinical Evidence

Peyronie’s disease is a condition that causes abnormal healing of the tunica albuginea, causing penile curvature. It is difficult to treat and its management is continuing to evolve. Proposed non-surgical treatments have included oral, topical, intralesional, extracorporeal shockwave, and traction therapy. The study of Peyronie’s disease is made difficult by heterogeneity in the timing of presentation, severity and characteristics of deformity, and associated complaints. Moreover, meta-analyses of studies are difficult due to inconsistencies across study endpoints and the duration of treatments. This article reviews the current clinical evidence and guideline recommendations, with a focus on an improvement in penile curvature.