Peyronie's Disease and Injectable Collagenase Clostridium histolyticum: Safety, Efficacy, and Improvements in Subjective Symptoms

Collagenase Clostridium histolyticum for Peyronie's disease: a contemporary atlas of complications and their management

INTRODUCTION

Collagenase Clostridium histolyticum (CCH) remains the only Food and Drug Administration-approved medical treatment for Peyronie's disease (PD). The initial IMPRESS I and II trials (Investigation for Maximal Peyronie's Reduction Efficacy and Safety), which led to Food and Drug Administration approval, revealed a rate of treatment-related adverse events as high as 84%. Studies fail to provide clear definitions of complications.

OBJECTIVES

To review complications, provide a CCH complication atlas, and propose management strategies for commonly encountered complications.

METHODS

We performed a literature review using PubMed. A photographic atlas was provided regarding complications in patients in a high-volume CCH center for PD.

RESULTS

Complications were identified and classified by nature and severity. We followed a standardized previously published grading system for hematomas. Complications include bruising, swelling, hematoma formation, back pain, and, rarely, corporal rupture. Complications were discussed, and hematomas were graded by penile surface area. Complication photographs were graded and displayed. Treatment-related adverse effects do not affect overall results.

CONCLUSION

Recognizing and grading complications associated with CCH therapy for PD is crucial for effective patient management and informed decision making. A standardized grading system allows for consistency in reporting and comparing hematoma complication rates across studies and patient populations. Herein we provide images that will help clinicians identify and confidently manage common complications that may occur in any CCH program.

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.

Expanded Utilization of Intralesional Therapies for Treatment of Peyronie's Disease

Purpose

In this narrative review we explore additional indications for which intralesional collagenase Clostridium histolyticum (CCH) injection therapy may be used, in addition to those utilized in the IMPRESS trials. The goal is to provide updated assessment of available intralesional therapies and justify whether to expand clinical indications based on advancements over the last decade.

Results

Patients receiving CCH in the acute phase of PD have shown significant improvement in penile curvature - which may be even more significant than reported due to progressive curvature over the longitudinal course of injection therapy. Across studies, patients with ventral plaques achieved the greatest curvature improvement (~30°) compared to PD patients with dorsal or lateral plaques. Patients with curvature > 90° have been minimally documented. However, the concept of patients with higher degree of curvature achieving more significant degrees of improvement prevails across studies. Studies including PD patients with volume loss deformities or indentation(s) focus on curvature improvement and do not gauge improvement in these girth loss or indentation features specifically. PD patients with calcification may benefit from CCH, however, critical analysis of included study designs and results compared to placebo do not lend for strong support of CCH in PD at this time.

Conclusion

Based on the most recent research, the use of CCH in the acute phase of PD and patients with ventral penile plaques may be effective and safe. The limited available research on the efficacy of CCH on calcified plaque(s) and curvature greater than 90° is promising, however, more research is needed to ensure safety and success in this patient cohort. Finally, the current literature continues to show the use of CCH is not effective in PD patients with volume loss, indentation, or hourglass deformity. When expanding the use of CCH to patients not originally included in the IMPRESS trials, providers must prioritize minimizing chances of potential injury to urethral tissue. Finally, further investigation is required to determine whether CCH has utility for curvature greater than 90° or calcified plaques, although the limited available literature is promising.

Predictors of Curvature Improvement in Men with Peyronie's Disease Treated with Intralesional Collagenase Clostridium Histolyticum

INTRODUCTION

Penile curvature is the most common abnormality that is observed by men with Peyronie's disease (PD). Collagenase Clostridium histolyticum (CCH) has become a standard treatment for PD patients.

AIM

To identify predictor factors associated with improvements of penile curvature outcomes in men with PD treated with CCH.

METHODS

We retrospectively collected the data of patients with PD treated with CCH up to 8 injections divided into 4 cycles between January 2014 and July 2020. Per protocol, penile curvature was assessed at baseline, and after the second and ford CCH cycle. If after cycle 2, curvature demonstrated no improvement, or penile curvature was significantly improved and the patient was happy, no further treatment was recommended. However, if penile curvature was significantly improved and the patient remained dissatisfied, 4 cycles were completed. Three categories of response were evaluated: improvement (≥10 degrees or ≥20%, either 1 happens), unchanged (±10 degrees or ±20%) or worsened (≥10 degrees or ≥20%, either 1 happens). Logistic regression analyses were performed to evaluate predictive factors associated with penile curvature improvements.

OUTCOMES

Degrees of the curvature changes between the baseline and after the cycles of CCH.

RESULTS

A total of 114 patients underwent CCH treatment. Median age was 57 years. Median PD duration was 11 months. At baseline, mean curvature was 47 degrees, 65% had dorsal curvature, 53% mid-shaft location, and 15% calcification. After CCH treatment, the mean final curvature was 40 degrees. A total of 44% improved the curvature, 39% had no change while 17% worsened after CCH treatment. Of men who had penile curvature improvement with CCH treatment, the mean curvature decreasing in degrees and percentage were 22 degrees and 41%, respectively. Men with baseline curvature ≤ 30, 31-59, and ≥ 60 degrees, the percentage curvature improvement were 29%, 43%, and 60%, respectively. Baseline curvature was the only significant predictor of penile curvature improvement after CCH (OR 1.33, 95% CI = 1.1, 1.7).

CLINICAL IMPLICATIONS

We confirmed baseline penile curvature is the most important predictive factor, and this is the first report describing proportions of penile curvature improvement with CCH treatment.

STRENGTHS AND LIMITATIONS

This study has several strengths, including the use of validated instruments. Nonetheless, there are limitations: the retrospective nature of the study, a single institution; and modelling device was not controlled.

CONCLUSION

Penile curvature improvement was significantly more common in patients with greater baseline curvature, reaching up to 60% for patients with ≥ 60 degrees.

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature

INTRODUCTION

Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities.

OBJECTIVES

To review the criteria used to define acute and chronic phase PD in modern PD intervention studies.

METHODS

We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis.

RESULTS

We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain.

CONCLUSION

Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.

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.

Cost of Intralesional Collagenase Clostridium Histiolyticum Therapy Versus Surgery for the Management of Peyronie's Disease: A Claims-Based Analysis (2009-2019)

BACKGROUND

Collagenase Clostridium histolyticum (CCH), which was approved by the FDA for the treatment of Peyronie's disease (PD) in 2013, may obviate the need for surgery but its historically high cost must be considered when offering CCH vs surgical intervention to affected patients.

AIM

To compare trends of intralesional injections vs surgical treatment for PD and assess the contemporary cost of treatment with CCH vs surgical intervention.

METHODS

We reviewed 2009-2019 MarketScan Commercial Claims data to identify all men 18 years and older with PD. CPT and HCPCS codes were used to identify PD treatments for each patient. Associated insurance claims in USD were summed for each treatment type.

OUTCOMES

Total and out-of-pocket costs, as well as frequencies, for treatments were calculated on a yearly basis and the Cochran-Armitage test was used to compare frequencies before and after FDA approval of CCH.

RESULTS

Of 89,205 men diagnosed with PD, 21,605 (24.2%) underwent treatment; most required only intralesional injections, however 1,519 (7.0%) received only surgical therapy and 1,951 (9.0%) required medical and surgical therapy. Intralesional CCH use sharply increased after its FDA-approval in 2013 with a concomitant fall of intralesional verapamil use. The use of both surgical plication and plaque grafting decreased steadily from 2009 to 2019. The median cost per patient for all 3 treatments increased over the study time-period: $1,856 to $3,196 for plication, $2,233 to $3,631 for plaque grafting, and $6,940 to $8,895 per cycle for CCH. Out-of-pocket median patient contribution for plication, plaque grafting, and per cycle intralesional CCH injection were similar over the study period and never exceeded $300.

CLINICAL IMPLICATIONS

CCH is significantly more expensive than any surgical treatment option, however, the out-of-pocket patient contribution for surgery and CCH are similar.

STRENGTHS & LIMITATIONS

This study incorporated all procedure costs and is the most contemporary, comprehensive, and accurate reflection of overall and out-of-pocket costs to patients for surgical and intralesional PD therapies. We anticipate these data to allow for a more complete discussion between patients and providers regarding their care. The use of a commercial claims database prohibited assessment of post-procedural costs and treatment outcomes.

CONCLUSION

CCH use has increased significantly since its FDA approval in 2013 with out-of-pocket patient contribution comparable to surgical therapy despite significantly higher total treatment costs. Walton EL, Quinn TP, Mulloy E, et al. Cost of Intralesional Collagenase Clostridium Histiolyticum Therapy Versus Surgery for the Management of Peyronie's Disease: A Claims-Based Analysis (2009-2019). Sex Med 2022;10:100517.

Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients

BACKGROUND

Intralesional collagenase such as Xiaflex (ILX) has become a standard treatment for Peyronie's disease (PD). Many robust studies have demonstrated its clear efficacy in the treatment algorithm.

AIM

To examine predictors of the patient decision to pursue ILX in PD patients.

METHODS

The study included PD patients (i) with stable disease (ii) who had doppler duplex ultrasonography (DUS) at least 6 months prior to analysis date and (iii) did not choose an operation. All patients received a standard discussion regarding treatment options, specifically, observation, ILX and penile reconstructive surgery (plication, plaque incision and grafting, implant surgery). Patients who opted to use ILX were compared to those who opted against it. Comorbidity, demographic and PD characteristics were recorded at the initial PD visit. All patients completed three validated questionnaires including the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire and a depression questionnaire (CES-D). Logistic regression was used to determine predictors of ILX use.

OUTCOMES

Predictors of ILX utilization.

RESULTS

Four hundred and fifty stable PD men had DUS completed 6 months before to allow sufficient time for treatment decision. Of these, 111 (24.7%) patients had ILX treatment and 339 (75.3%) did not. Mean age, relationship status and pain occurrence were similar between groups, but ILX patients had less bother defined as PDQ ≥ 9 (46.8% vs 53.7%, P = .02). ILX patients had more complex curves (79.3% vs 47.8%, P < .01) and more severe instability (32.4% vs 15.3%, P = .01). ILX patients also had higher PDQ domain scores (Psychological 11.5 ± 6.4 vs 7.5 ± 6.2, P < .01; Pain 6.2 ± 6.0 vs 4.3 ± 5.6, P = .02; and Bother 9.8 ± 4.7 vs 6.6 ± 4.8, P < .01). On univariable statistics, significant bother (OR 2.41, 95% CI 1.36-4.28, P<0.01), complex curvature (OR 4.18, 95%CI 2.52-6.93, P < .01), moderate and/or severe instability (OR 1.98, 95%CI 1.18-3.30, P < .01) and PDQ-Bother scores (OR 1.15, 95%CI 1.08-1.22 P < .01) predicted ILX use. On multivariable analysis, instability (OR 2.58, 95%CI 1.02-6.57, P = .05) and significant bother (OR 1.23, 95%CI 1.04-1.45, P = .01) predicted ILX use.

CLINICAL IMPLICATIONS

Educates providers as to which patients are more likely to choose ILX.

STRENGTHS & LIMITATIONS

Our study has a large sample size and all patients received the same standardized treatment discussion. Our study is limited by the absence of insurance data on all patients, and its retrospective single center design.

CONCLUSION

ILX was chosen by the minority of stable PD patients. While moderate to severe instability and significant bother is predictive of ILX use, other demographic factors including relationship status, sexual orientation or pain were not. Punjani N, Nascimento B, Salter C, et al. Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients. J Sex Med 2021;18:1258-1264.

Continuing Collagenase Clostridium Histolyticum Injections Among Initial Nonresponders Results in Significant Curvature Improvements in the Majority of Peyronie's Disease Men

BACKGROUND

It is currently unclear if men with Peyronie's Disease (PD) who achieve minimal benefits with the first 2 series of Collagenase Clostridium Histolyticum (CCH) injections should continue with additional injections.

AIM

To analyze curvature improvements from the final two series of CCH injections based on amount of improvement during the first 2 series.

METHODS

A prospective registry was analyzed of all men undergoing CCH injections for PD at a single institution. Men were included if they had completed a full 4 series (8 injections) of CCH and had baseline, interval (after 2 series), and/or final (after 4 series) curvature assessments available. Men were stratified into cohorts using baseline-to-interval assessments of ≤10° (or ≤20%) and >10° (or >20%), and improvements were compared using interval-to-final assessments.

OUTCOMES

The primary outcome was interval-to-final curvature improvements stratified by ≤10°/>10° or ≤20%/>20% improvements achieved during the baseline-to-interval period. Secondary outcomes included analyses of demographic and pathophysiologic variables to determine associations with significant improvements during the final 2 CCH series.

RESULTS

A total of 296 PD men were identified as receiving at least one CCH injection, of whom 175 had baseline-to-interval, 84 interval-to-final, and 115 with baseline-to-final measurements. Mean age was 56.6, PD duration 28.6 months, baseline curvature 63.4°, hourglass deformity 36.2%, and calcification 20%. Mean overall curve improvement was -21.5° (33.1%). Among men who experienced ≤20% improvements after 2 series, the mean subsequent curvature change was -24.6% during the final two series (vs +4.3% of those with >20% initial improvement, P< .001), and they were 2.7x more likely to experience >20% subsequent curve improvements. Thirty-one percent of those who achieved >10° during the first 2 series experienced benefits during the final 2 series compared to 70% of men who had ≤10° improvement initially. No demographic or pathophysiological variables predicted likelihood for improvements during the final 2 series of injections.

CLINICAL IMPLICATIONS

Men who fail to achieve significant benefits with 2 series of CCH injections may benefit from completing the final 2 series.

STRENGTHS AND LIMITATIONS

Strengths including a relatively large, prospective series. Limitations include a single center, nonrandomization, nonblinded assessments, and restriction to men who completed eight injections.

CONCLUSIONS

In the current series, approximately 2/3 of men who fail to achieve >10° or 20% curve improvements with an initial 2 series of CCH injections achieved >10° or 20% improvements with the subsequent 2 series. Alom M, Burgon H, Ziegelmann M, et al. Continuing Collagenase Clostridium Histolyticum Injections Among Initial Nonresponders Results in Significant Curvature Improvements in the Majority of Peyronie's Disease Men. J Sex Med 2021;18:1092-1098.

Efficacy and safety of collagenase Clostridium histolyticum in Peyronie's disease following a modified treatment protocol

INTRODUCTION

Collagenase Clostridium histolyticum (CCH) is the only approved treatment for conservative management of Peyronie's disease (PD) that has demonstrated efficacy and safety in clinical trials. However, as the standard treatment protocol is time and resource consuming, we are introducing a new CCH treatment protocol with a more cost-effective profile. Our goal is to evaluate its efficacy and safety.

MATERIALS AND METHODS

We included patients with PD in stable phase, with curvatures of 30-90degrees. Ventral curvatures and complex deformities were excluded. The treatment protocol consists of a full dose of CCH injected along the PD plaque, forming two lines of four injections. Patients were educated in daily penile modeling activities. The need for a new treatment cycle, up to a maximum of 8 cycles or until the 30-degree curve was decreased, was reevaluated every 4weeks. Changes in curvature and number of cycles were recorded to evaluate the efficacy. Regarding safety evaluation, treatment-related adverse events (TRAEs) were recorded, including rupture of the corpora cavernosa, penile hematoma, hematuria, and local infection.

RESULTS

Thirty-one patients were treated under the modified protocol. The mean initial curvature was of 49.84 (±15.83) degrees. Curvature improvement was recorded in 25 patients (80.6%), with a mean absolute reduction of 20.65 (±15.42) degrees and relative reduction of 44%. The mean curvature after treatment was 30.67 (±17.25) degrees. Most patients required one (19.4%) or two (54.8%) injections. No patient presented TRAEs.

CONCLUSIONS

The results suggest that the modified CCH treatment protocol is effective and safe, but more studies should be carried out to optimize the current standard protocol.

The Management of Penile Fracture: a Review of the Literature with Special Consideration for Patients Undergoing Collagenase Clostridium Histolyticum Injection Therapy

PURPOSE OF REVIEW

To review the current literature on acute management of traumatic penile fracture, with a specific discussion of those injuries following collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie's disease.

RECENT FINDINGS

The immediate repair of traumatic penile fracture injury is associated with significantly better prognosis for long-term sexual health. Corporal disruption following CCH administration has several distinct features, and the trend is to manage these patients conservatively in the absence of urethral injury. Traumatic penile fracture repair continues to have excellent results when performed immediately following injury. The post-CCH treatment setting portends increased difficulty during surgical management and can be successfully managed in most cases by conservative measures.

Conservative management of suspected fractures in men undergoing collagenase clostridium histolyticum for Peyronie's Disease is not associated with worsening of erectile function

The optimal management of suspected penile fractures post collagenase clostridium histolyticum (CCH) remains indeterminate, with some advocating for observation and others surgical repair. To address this issue, the current study sent surveys to 158 men with Peyronie's Disease (PD) who completed four CCH injection series. The survey included the Erectile Function Domain from the International Index of Erectile Function (IIEF-EFD) and questions regarding potential symptoms of corporal rupture (hematoma, popping, and detumescence). Men were categorized as having a suspected fracture (SF+) if they reported a popping sensation or rapid detumescence. All SF(+) men were managed conservatively without surgical intervention. Results were compared statistically against baseline IIEF-EFD values and between SF(+) and SF(-) groups. The key study objective was to determine whether erectile function was negatively impacted by conservative management of suspected fractures. Of the 53 returned surveys, 45 had complete data for review. The sample was statistically representative of the broader cohort of 158 men, except being older (60.0 vs 57.1 [SD 6.0 vs 9.0], p = 0.01) with shorter durations of PD (median 9 [IQR 5, 19] mo vs 13 [IQR 8, 24], p = 0.01). Overall, 7/45 (16%) of men were defined as SF(+), with all fractures occurring within 6 weeks of CCH administration. No demographic or pathophysiologic characteristics predicted SF(+). Importantly, SF(+) men did not experience worsened erectile function compared to SF(-), with a median IIEF-EFD change of +2 vs +1, p = 0.16, respectively. Curvatures were improved to a greater degree among SF(+) men (primary: median -30 [IQR -20, -32.5] vs -15 [-5, -26], p = 0.04; composite: -35 [-25, -40] vs -25 [-7, -30], p = 0.15). We concluded that suspected penile fractures in PD men undergoing CCH may be reasonably managed without surgical intervention and portend greater improvements in curvature correction.

Treatment Trends and Cost Associated With Peyronie's Disease

INTRODUCTION

Providers may use several treatment options for patients with Peyronie's disease; however, it is unclear whether practice patterns have evolved over recent years and if this has impacted cost.

AIMS

To investigate trends in the treatment of Peyronie's disease over time and the associated costs using a national, commercial insurance claims database.

METHODS

A retrospective cohort study was conducted using claims from the Truven MarketScan database from 2007 to 2018 for men with Peyronie's disease. Cost was estimated as either the sum of prescription oral or injectable treatment costs or as the single net cost associated with the operative procedure.

MAIN OUTCOME MEASURES

Frequency of use of various treatments for Peyronie's disease and associated costs were assessed as trends over the timeline by year.

RESULTS

The estimated annual incidence of Peyronie's disease in this population rose from 61 to 77 per 100,000 patients over the included years, and the percent annual treatment rate rose from 17.8% to 26.2%. Colchicine was the most commonly prescribed oral agent in 2007 used in 22% of treated individuals; by 2018, pentoxifylline was the most common prescribed oral agent used in 33%. In 2007, 11% of treated patients received intralesional verapamil; however, by 2018, 24% received injectable collagenase, whereas <1% received intralesional verapamil. The mean annual, per-individual cost of Peyronie's disease treatment increased from $1,531 in 2007 to $10,339 in 2018. The cost increase was greatest for injectable therapies, which rose from $811 per individual in 2007 to $16,184 in 2018, a 19-fold increase.

CONCLUSIONS

Diagnosis and treatment of Peyronie's disease is increasing over time. Pentoxifylline has become the most common oral prescription, whereas injectable collagenase has become most common injection. The mean cost associated with Peyronie's disease treatment increased more than 5 times from 2007 to 2018 corresponding with Federal Drug Administration's approval of injectable collagenase. Loftus CJ, Rajanahally S, Holt SK, et al. Treatment Trends and Cost Associated With Peyronie's Disease. Sex Med 2020;8:673-678.

Efficacy of Collagenase Clostridium histolyticum (Xiapex®) in Patients with the Acute Phase of Peyronie's Disease

BACKGROUND AND OBJECTIVE: Plaque formation ordinarily takes place in the acute phase of Peyronie's disease. There is no unanimous consent regarding the management of the acute phase of Peyronie's disease. The objective of this study was to evaluate the advantages of using a single intralesional injection of collagenase Clostridium histolyticum in patients with the active phase of Peyronie's disease and to assess its effect on disease progression by reducing penile curvature and ameliorating pain during sexual intercourse.

METHODS

Sexually active men aged older than 18 years with the acute phase of Peyronie's disease were enrolled. All patients received treatment with a single intralesional injection of collagenase Clostridium histolyticum. The primary outcome of the study was the change in penile curvature after treatment while secondary outcomes were the change in sexual function (International Index of Erectile Function [IIEF-5]) and in the Peyronie Disease Questionnaire (PDQ) and its sub-scores, PDQ-PS (psychological symptoms), PDQ-PP (penile pain) and PDQ-BD (bother disease).

RESULTS

Overall, 74 patients were enrolled. Mean penile curvature at baseline was 41.1° ± 12.2°. The mean changes before and at the 3-month evaluation in terms of penile curvature, Visual Analog Scale score at rest, and Visual Analog Scale score during intercourse were - 19.3 ± 8.4 (p < 0.0001), - 0.8 ± 1.1 (p < 0.0001) and - 3.8 ± 0.9 (p < 0.0001) with the benefit persisting also after 6 months. Moreover, improvements of mean IIEF-5 score (1.1 ± 0.9, p = 0.03; 0.9 ± 0.5, p = 0.02), PDQ-PS (- 2.7 ± 2.2; - 2.5 ± 2.0, p = 0.01), PDQ-PP (- 1.2 ± 1.6; - 1.1 ± 1.2, p = 0.02) and PDQ-BD (- 3.8 ± 3.4; - 3.5 ± 3.1, p = 0.001) were observed 3 and 6 months after the end of treatment, respectively. At the multivariable regression analysis, the time since disease onset (modelled with non-linear terms) and baseline curvature were independently associated with the degree of curvature improvement (coefficient: 0.30; 95% confidence interval 0.16-0.44) after a single intralesional injection (all p < 0.03).

CONCLUSIONS

Although intralesional therapy with collagenase Clostridium histolyticum is not yet indicated for the acute phase of Peyronie's disease, these preliminary results suggest the effectiveness of this minimally invasive option by improving penile curvature and IIEF-5 and PDQ scores.

Safety and Efficacy of Collagenase Clostridium histolyticum in the Treatment of Acute Phase Peyronie's Disease: A Multi-institutional Analysis

OBJECTIVE

To study, in a multi-institutional setting, the efficacy/safety outcomes in acute phase Peyronie's disease (PD) of multiple high-volume centers employing CCH to treat PD, which is defined as the abnormal formation of fibrous plaque(s) in the tunica albuginea of the penis. It is a chronic condition that afflicts 3%-13% of the US male population. There is no current multi-institutional research on the efficacy and safety of collagenase Clostridium histolyticum (CCH) in the treatment of acute phase PD.

METHODS

Retrospective data were collected for consecutive patients with PD who underwent treatment with CCH between April 2014 and March 2018 at 5 institutions. 918 patients were included. Patients with duration of PD no longer than 6 months at presentation qualified as being in the acute phase of PD. Main outcomes of interest include the change in curvature after receiving CCH therapy, and frequency of serious treatment-related adverse events. Successful improvement in curvature is defined as an at least 20% decrease in penile curvature from baseline after CCH therapy.

RESULTS

A total of 918 patients were included in the analysis, of which 134 (14.6%) qualified as acute phase PD (group 1) and the remaining 784 (85.4%) qualified as stable phase (group 2). Mean duration of PD was 4.44 ± 1.68 months for group 1, and 40.8 ± 61.2 months for group 2. There was no significant difference in final change in curvature between acute and stable phase of PD (13.5° vs 15.6°, P = .09). There was no statistically significant difference in frequency of treatment-related adverse events between the acute phase (16 patients, 11.9%) and the stable phase (77 patients, 9.8%; P = .44). In our multivariate analysis, only number of CCH cycles received was predictive of improvement of curvature.

CONCLUSION

This large multi-institutional analysis confirms that CCH therapy is as safe and efficacious in acute phase PD as it is in stable phase PD.

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.

Evaluating collagenase Clostridium histolyticum administration protocols in the treatment of Peyronie's disease

PURPOSE OF REVIEW

Treatment of Peyronie's disease with collagenase Clostridium histolyticum (CCh) has gained world-wide adoption following the phase III clinical trials IMPRESS I and II. However, the optimal treatment parameters remain largely unknown. Many groups have made modifications to CCh treatment in Peyronie's disease in recent years. This review aims to discuss the variations in CCh treatment reported and associated outcomes.

RECENT FINDINGS

Variations in CCh treatment protocols include administering higher CCh doses (0.9 mg) less frequently (q1month), use of home penile modeling, use of angulating penile traction devices, and vacuum therapy devices. Authors have reported different injection techniques to include three-point fans and tunneling techniques. Patient selection has expanded to include and evaluate responses among men with some extent of plaque calcification, and ventral curves.

SUMMARY

Since publication of the IMPRESS trials, several variations of CCh treatment have been reported with similar treatment responses to the original trials. However, future studies are required with prospective, randomized comparative designs to identify the optimal treatment strategies for men with Peyronie's disease.

Review of Intralesional Collagenase Clostridium Histolyticum Injection Therapy and Related Combination Therapies in the Treatment of Peyronie's Disease (an Update)

INTRODUCTION

Collagenase Clostridium histolyticum (CCH) is an injectable agent used to treat Peyronie's disease (PD) by enzymatically degrading the interstitial collagen in plaques. CCH has been administered via multiple treatment protocols, in combination therapies, to patients with varying curvatures and in both the acute and stable phases of this condition.

OBJECTIVES

To review the current literature and provide an update on CCH as an injectable therapy for PD, as a singular therapy or in conjunction with combination therapies, and its associated complications. We provide a brief background of PD treatments, evaluate CCH efficacy in penile curvature reduction and subjective improvement in a variety of protocols, and compare combination therapies (penile traction, sildenafil), plaque location, and efficacy in both acute and stable diseases.

METHODS

We performed a systematic review of the existing PubMed literature pertaining to CCH injection therapy in the treatment of PD and compared the effectiveness to different treatment modalities.

RESULTS

CCH is a safe and effective injectable agent for all curvature directions in both acute and stable PD. It can be used in conjunction with multiple penile modeling techniques, in combination with sildenafil, and following a shortened administration protocol. Moderate to severe treatment-related adverse events occur at a rate of 9% and are typically managed conservatively.

CONCLUSION

Intralesional injections of CCH are FDA approved as a nonsurgical treatment for men with PD. The IMPRESS trials were instrumental in demonstrating the efficacy and safety of CCH and provided a standard protocol for administration. Additional studies are required to optimize treatment protocols and use in combination therapies. Further investigation of patients with ventral curvatures, hourglass deformities, and those in acute phase is needed. Natale C, McLellan D, Yousif A, et al. Review of Intralesional Collagenase Clostridium Histolyticum Injection Therapy and Related Combination Therapies in the Treatment of Peyronie's Disease (an Update). Sex Med 2021;9:340-349.

Minimally invasive therapies for Peyronie's disease: the current state of the art

Peyronie's disease (PD) is a relatively common condition that can result in significant penile deformity, sexual dysfunction, and psychological bother. Surgical straightening offers the highest probability of success during the stable phase of the disease. However, for men in the acute phase of PD or for those with less severe deformity who elect to avoid surgery, a variety of non-surgical treatment options are available. Oral therapies, including L-citrulline and pentoxifylline, are most useful as part of a combination regimen rather than as monotherapy. Intralesional therapy with IFN-α2b, verapamil, and collagenase clostridium histolyticum (CCH) can cause significant reduction in penile curvature, yet these results may not be clinically significant for men with more severe curvature. Further investigation into the timing of administration and optimal patient characteristics is required. Penile traction therapy offers a clinically significant improvement in penile length and curvature. However, this has traditionally required hours of daily therapy. Overall, a combination of oral, topical, injection and traction therapies may provide the most significant benefit among the non-surgical modalities for PD.

Noninvasive Treatment Options for Peyronie's Disease

INTRODUCTION

Evidence for noninvasive management of Peyronie's disease contains many options with varying levels of evidence for each. Many first-line treatments recommended by urologists lack strong evidence for their use.

AIM

We summarize the noninvasive (oral medications, topical medications, traction, vacuum erection devices, extracorporeal shock wave therapy, intracavernosal injections and electromotive therapy) treatment options for Peyronie's disease and provide the levels of evidence for each.

METHODS

A literature search of PubMed, EMBASE, Cochrane Library, and ClinicalKey databases was conducted, current up to April 2019.

MAIN OUTCOME MEASURE

For each treatment modality, we measured level of evidence, change in penile curvature, change in erectile function, the percentage of patients with improved angulation, and pain scores.

RESULTS

There is weak evidence to support the use of oral or topical medications. Higher levels of evidence exist for intracavernosal injections and extracorporeal shock wave therapy and may be helpful in certain patient populations.

CONCLUSION

The mechanisms behind Peyronie's disease are not fully understood. Penile injections provide the highest quality of evidence for noninvasive treatment. Ory J, MacDonald L, Langille G. Noninvasive Treatment Options for Peyronie's Disease. Sex Med Rev 2020;8:603-614.

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.

Optimizing collagenase Clostridium histolyticum therapy for Peyronie's disease using a novel approach with percutaneous needle tunnelling

OBJECTIVES

To compare the efficacy and safety of a combined treatment of percutaneous needle tunnelling (PNT) and a modified collagenase Clostridium histolyticum (CCH) protocol (PNT/CCH) vs the modified protocol alone (CCH) in the treatment of Peyronie's disease (PD).

PATIENTS AND METHODS

A prospective registry of patients treated with a modified CCH protocol was maintained between June 2014 and February 2018. The last 50 patients received PNT as an adjuvant therapy (PNT/CCH), and their data were compared with those of the other 94 patients treated previously (CCH). PNT involves the creation of multiple holes made percutaneously in the plaque before each injection. The modified protocol consisted of two collagenase injections, at 1-week intervals, followed by penile modelling. Patients used penile traction therapy, tadalafil and pentoxifylline for the next 2 months and were followed up for 6 months. The main outcome was improvement of curvature. Secondary outcomes were improvements in erectile function, PD symptoms, stretched penile length and satisfaction.

RESULTS

Improvement in curvature was greater in patients in the PNT/CCH group than in the CCH group (mean ± sd 19.2 ± 6.1° vs 12.7 ± 5.0°; P < 0.001 [36.2 ± 12.5% vs 28.1 ± 14.5%; P = 0.001]). Compared with baseline, both interventions were associated with significant improvement in secondary outcomes. The main complications were ecchymosis, bruising and penile pain, with no significant differences between groups.

CONCLUSIONS

Treatment of PD with CCH using our modified protocol in combination with PNT is safe and more effective than the modified protocol alone, with the potential for improved cost-effectiveness.

Management of Peyronie's disease with collagenase Clostridium histolyticum in the acute phase

INTRODUCTION

Peyronie's disease (PD) can affect men of all ages and is associated with penile pain as well as curvature and erectile dysfunction. Treatment modalities for PD include conservative, less invasive and surgical treatments. Choice of treatment depends on the disease's phase. Injection of collagenase Clostridium histolyticum (CCH) is only the Food and Drug Administration approved treatment for the management of the chronic phase of the disease. Only a few limited studies have evaluated its potential benefits during the acute phase.

AIM

To evaluate the current evidence on the use of injectable CCH during the acute or active phase of PD.

METHODS

We performed a PubMed database search for articles published between 2015 and 2018 that investigated the use of CCH for the management of the acute phase of PD. Search keywords included "Peyronie's disease", "collagenase Clostridium histolyticum", and "acute phase".

MAIN OUTCOME MEASURES

Changes in penile curvature after treatment with injectable CCH.

RESULTS

Mean curvature decrease ranged between 15.8° and 22.6° corresponding to 27.4-37.4% decrease from baseline after 2.5-4 cycles, corresponding to 5-8 injections, of CCH treatment in patients during the acute phase of PD.

CONCLUSIONS

Intralesional CCH injection therapy during the acute phase of PD can be both safe and effective and clinically significant improvements in penile curvature may be achieved. Larger multi-institutional studies are, however, still needed to confirm these results and validate this additional indication for CCH.

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.

Review of Management Options for Active-Phase Peyronie's Disease

INTRODUCTION

Peyronie's disease (PD) is a fibrotic disorder that leads to plaque formation in ∼3-9% of adult men. Connective tissue buildup results in plaque formation, penile curvature and shortening, and in some cases, pain. In the active phase of PD, penile pain is a common symptom, often accompanied by progression in curvature. Treatment options for PD include oral drugs, topical cream, intralesional injections, traction, and shock wave therapy. This article reviews the different treatment options for active-phase PD.

AIM

To provide a comprehensive review of the current evidence-based treatments, focusing on active-phase PD.

METHODS

A PubMed database search was performed for studies on conservative therapy. We reviewed current clinical practices and trials for the treatment of active-phase PD and assessed their applicability as treatment options.

MAIN OUTCOME MEASURE

Define the most recent and effective therapies for the improvement in penile curvature in men presenting with acute PD.

RESULTS

A number of trials have resulted in significant benefits in the treatment of PD. Many of the oral therapies studied improved patient outcomes, but the data are insufficient. Similarly, there is no approved topical therapy by guidelines. The best options are intralesional injections of collagenase Clostridium histolyticum (CCh) and interferon-α2b. Shock wave therapy is not recommended for treatment of curvature, but has been shown to improve pain. Traction therapy may have a role in improving PD curve and penile length.

CONCLUSION

PD remains a challenge for urologists. Evidence suggests that, for oral therapy, a combination of drugs produces better results. Shock wave therapy is still unproven. Intralesional therapy delivers the best evidence for improvement in the active phase. CCh is the only FDA-approved treatment option available. Penile traction therapy may improve patient outcomes. Brimley SC, Yafi FA, Greenberg J, et al. Review of Management Options for Active-Phase Peyronie's Disease. Sex Med Rev 2019;7:329-337.

Contemporary surgical and non-surgical management of Peyronie's disease

Numerous treatments have been proposed for Peyronie's disease (PD). As the evidence base has expanded, the field of operative and non-operative options for patients has narrowed. Collagenase clostridium hystolyticum (CCH) injection now comprises the medical option, and surgical possibilities entail penile plication, plaque incision/excision and grafting, and prosthesis implantation. Still, questions abound regarding the optimal approach and indication for each of these treatments. We conducted a review of literature exploring the contemporary management of PD with a particular focus on work since the last American Urologic Association's (AUA) guidelines update for PD. Recent results and discussion indicate trends toward minimal invasiveness, toward a more holistic approach to the PD patient, and away from algorithmic management, galvanized, in part, by data challenging long-held beliefs.

Digesting a Path Forward: The Utility of Collagenase Tumor Treatment for Improved Drug Delivery

Collagen and hyaluronan are the most abundant components of the extracellular matrix (ECM) and their overexpression in tumors is linked to increased tumor growth and metastasis. These ECM components contribute to a protective tumor microenvironment by supporting a high interstitial fluid pressure and creating a tortuous setting for the convection and diffusion of chemotherapeutic small molecules, antibodies, and nanoparticles in the tumor interstitial space. This review focuses on the research efforts to deplete extracellular collagen with collagenases to normalize the tumor microenvironment. Although collagen synthesis inhibitors are in clinical development, the use of collagenases is contentious and clinically untested in cancer patients. Pretreatment of murine tumors with collagenases increased drug uptake and diffusion 2-10-fold. This modest improvement resulted in decreased tumor growth, but the benefits of collagenase treatment are confounded by risks of toxicity from collagen breakdown in healthy tissues. In this review, we evaluate the published in vitro and in vivo benefits and limitations of collagenase treatment to improve drug delivery.

Intralesional collagenase Clostridium histolyticum in the management of Peyronie's disease: current best practice

The use of Clostridium histolyticum collagenase (CCH) has become increasingly widespread for the treatment of Peyronie's disease (PD) in recent years. Numerous trials have confirmed both its safety and efficacy in appropriately selected patients with this condition. The purpose of this review is to examine pivotal trials demonstrating the efficacy of CCH, revisit viable candidates for treatment with intralesional injection therapy, and provide a summary of injection technique and appropriate management of patients receiving this treatment at the time of therapy and in follow up.

Racial variations in response to intralesional collagenase clostridium histolyticum in men with Peyronie's disease

Background

An examination of potential racial variations between Caucasian American (CA) and African American (AA) men in the efficacy and safety of collagenase clostridium histolyticum (CCH) in the treatment of Peyronie’s disease (PD).

Methods

We retrospectively reviewed the records for all patients treated with CCH for PD between 04/2014 and 05/2017. Patients were divided into two groups based on their self-reported race. The primary outcomes of interest were final change in curvature after CCH treatment regardless of number of CCH cycles received, and frequency of treatment-related adverse events (TRAEs).

Results

A total of 159 patients were included in the study, of which 146 (91.8%) were CA while 13 (8.2%) were AA. Mean duration of PD was 28.3 months for CA patients and 16.8 months for CA patients (P=0.436). There was no significant difference in final change in curvature CA and AA patients (15.9° vs. 13.1° respectively, P=0.445). There was no statistically significant difference in frequency of TRAEs between CA patients (17, 12%) and AA patients (0, 0%) (P=0.208).

Conclusions

Although racial variations in efficacy and safety of CCH in patients with PD have not been addressed in the literature, preliminary results from our study suggest that CCH therapy may be equally efficacious and safe in both CA and AA men. There was no statistically significant difference in final change in curvature, International Index of Erectile Function (IIEF) scores, penile length, or TRAEs after CCH treatment between CA and AA patients.

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.