Medical Treatments of Peyronie's Disease: Past, Present, and Future

Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation

BACKGROUND

Peyronie's disease (PD) is a challenging clinical entity. To assist clinicians with diagnosis and management, four separate organizations have published PD guidelines over the past five years, but there remains a lack of consensus and data-driven recommendations for many aspects of diagnosis and treatment.

AIM

To compare and contrast PD guidelines, highlighting key similarities and differences among the guideline panel recommendations and identify areas for further research.

METHODS

We performed an extensive review to compare and contrast diagnosis and treatment recommendations from publically available published PD guidelines from four different organizations: American Urological Association, European Association of Urology, Canadian Urologic Association, and the International Society of Sexual Medicine.

OUTCOMES

Key similarities and differences with regards to definition, evaluation, nonsurgical and surgical treatments were compared.

RESULTS

Points of general consensus among the guideline panels included: History is adequate for diagnosis of PD, and intracavernosal injection is a gold standard to evaluate penile deformity prior to invasive intervention. Careful counseling with shared decision-making is required prior to treatment. In general, plication and incision and/or grafting surgery is reserved for patients with preserved erectile function whereas penile prosthesis implantation is the only surgical option for PD patients with erectile dysfunction. Overall, nonsurgical treatments have inferior evidence of efficacy with these being the main area of controversy; however, all societies recognize that intralesional injections may be used. 0Further research into the pathophysiology of PD may direct novel treatments targeted towards early intervention and rigorous outcomes research may direct best practices for the surgical treatment of PD in the future.

CLINICAL IMPLICATIONS

PD is a challenging clinical entity. Direct comparison of the published PD guidelines highlights clear standards of care as well as areas where more research is needed to promote higher levels of evidence-based practice.

STRENGTHS & LIMITATIONS

To our knowledge this is the first report to directly compare and contrast published guidelines pertaining to the diagnosis and management of PD. Limitations include the lack of evidence-quality review pertaining to individual guideline recommendations, although this was not the aim of this review.

CONCLUSION

We highlight consensus of major urologic societies on many aspects of work up and management of PD with notable exceptions which may guide further research. Manka MG, White LA, Yafi FA, et al. Comparing and Contrasting Peyronie's Disease Guidelines: Points of Consensus and Deviation. J Sex Med 2021;18:363-375.

Medical, non-invasive, and minimally invasive treatment for Peyronie's disease: A systematic review

BACKGROUND

The treatment of Peyronie's disease (PD) remains a dilemma as the true pathogenesis of PD remains an enigma. Consequently, new molecules and therapies continue to evolve. The safety and efficacy of conservative treatment for PD have not yet established.

OBJECTIVES

To provide the available information of the status of conservative therapy for PD.

METHODS

A systematic literature search was conducted using PubMed, EMBASE, and the Cochrane Library for English-language journal articles between January 2000 and July 2019, using the terms "Conservative treatment for PD", "medical treatment for PD", "non-invasive therapies for PD" and "minimally invasive therapies for PD". This systematic review was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) system. We also manually reviewed references from selected articles. The risk of bias in the included RCTs was assessed using the Cochrane Risk of Bias Assessment tool (RoB 2).

RESULTS

Conservative treatment is accepted as the initial treatment step in most of the cases. This kind of therapy includes various methods of treatment such as medical, non-invasive, and minimally invasive therapies. Ideal management of PD is not yet available. It is not possible to assess the value of treatment without well-designed, randomized, placebo-controlled, large-scale clinical studies.

CONCLUSION

Optimistically, in the near future, we may witness emergence of efficacious new agents and modalities to revolutionize medical, non-invasive, and minimally invasive treatment of this devastating condition.

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.

Evolving therapies for Peyronie's disease: how can we work towards new drugs?

Peyronie’s disease (PD) is an idiopathic chronic fibrotic disease that causes a penile curvature (PC), subsequent erectile dysfunction (ED) and impaired sexual intercourse in patients. As of yet, there are no reliable non-surgical treatment options available. Intralesional injection with collagenase Clostridum Histolyticum has been FDA approved since 2013, but post-approval studies have not been unanimously positive. Moreover, it renders a curvature improvement of only 30% on average, usually still requiring surgical intervention to remedy PC. Therefore, there is a need for drugs which could prevent surgery altogether. Development of new drugs can either be through a target-based or phenotypic assay-based approach. The current in vivo model for PD is dependent on treatment of primary PD-derived fibroblasts with transforming growth factor-β1. Moreover, despite the existence of a genetic in vivo PD model, it does not allow for drug screening or testing. While some advances have been made in the past few years, new in vivo and in vivo systems and well-designed studies are urgently needed for the non-surgical treatment of PD.

Peyronie's Disease Intervention Studies: An Exploration of Modern-Era Challenges in Study Design and Evaluating Treatment Outcomes

INTRODUCTION

Peyronie's disease (PD) is characterized by pain, deformity, sexual dysfunction, and psychological bother. Several treatments are available with varying levels of efficacy, and significant limitations exist with the currently available literature.

AIM

To explore modern-era methodological challenges inherent to PD research as they pertain to intervention studies.

METHODS

We performed a critical review of the PD intervention literature to identify common methodological challenges with emphasis on aspects of patient assessment and treatment outcomes, study design, and statistical analysis. The key objective was to provide an impetus on which to build future research protocols, rather than focus on weaknesses with any individual studies.

MAIN OUTCOME MEASURE

Expert opinion was used to summarize limitations with commonly reported objective outcomes such as penile curvature, girth, and length along with imaging modalities and objective questionnaires. Appropriate study design and statistical analysis were also reviewed to discuss common pitfalls in the PD literature.

RESULTS

There are multiple shortcomings inherent to studying objective PD outcomes such as penile curvature, girth, and length. These include lack of standardized protocols for preintervention and postintervention assessment, interobserver and intraobserver variability, and lack of consistent definitions for what defines an objective outcome as clinically "meaningful" for patients. Similarly, imaging studies including penile ultrasound are subject to marked variation, thereby limiting their utility to measure predefined primary or secondary study outcomes including cavernosal artery hemodynamics and penile plaque size. Objective and validated questionnaires such as the Peyronie's Disease Questionnaire and International Index of Erectile Function require that patients have recently engaged in sexual activity, which is challenging for many patients as a result of penile deformity with PD. Finally, careful study design and statistical analysis (including appropriate study power) are imperative to ensure reliable results. Current shortcomings in the majority of studies contribute to the low level of evidence available for most PD interventions.

CLINICAL IMPLICATIONS

Future PD intervention studies should focus on optimizing study design and statistical analysis. Furthermore, authors must incorporate standardized protocols for assessing preintervention and postintervention outcomes.

STRENGTH & LIMITATIONS

The current analysis and recommendations for future study are based on the expertise and opinion of the manuscript authors.

CONCLUSION

Multiple areas of weakness in study design, statistical analysis, and patient outcomes assessment limit the reliability of data derived from PD intervention studies in the modern era. The global themes identified herein should serve as a basis upon which to build future research protocols. Ziegelmann MJ, Trost LW, Russo GI, et al. Peyronie's Disease Intervention Studies: An Exploration of Modern-Era Challenges in Study Design and Evaluating Treatment Outcomes. J Sex Med 2020;17:364-377.