Multimodal treatments based on Tadalafil during acute phase of Peyronie's disease: experience at two referral academic centers

AIM

The purpose of this study is to identify the clinical outcomes of patients during acute phase of Peyronie's disease (PD) treated with daily Tadalafil 5 mg associated with non-surgical treatments such as intra-plaque verapamil injections (IVI), vacuum erection devices (VED) or extra corporeal shockwave therapy (ESWT).

METHODS

445 patients with PD in acute stage were treated as it follows: Group 1(G1) 117 men with only Tadalafil 5 mg once a day for 3 months; Group 2(G2) 106 men with IVI plus Tadalafil 5 mg for a period of 12 weeks; Group 3(G3) 124 men that received ESWT for 6 weeks plus Tadalafil with the same protocol of G1; Group 4(G4) 98 men with VED plus Tadalafil 5 mg for 3 months. There were assessed at baseline and follow-up: Erectile dysfunction (ED), presence and severity of painful erections, penile plaque size and penile curvature degree. The results were evaluated at baseline and 3,6,12 months.

RESULTS

Not statistically significant differences emerged between the two groups at baseline, except for higher presence of patients with ED in in G3(7.4%) vs other groups(p < 0.001). Three months after the treatment in G3 men had a significant reduction of penile curvature degrees after 1 year by treatments, whereas pain in an erection or during intercourse was resolved completely in 75% of the patients.

CONCLUSIONS

Our study highlights that multimodal therapy has beneficial long-term effects not only in the decrease of ED symptoms, but also in the relief of the penile curvature and the quality of life.

Taping alone for persistent ventral curvature after urethral plate transection in hypospadias

INTRODUCTION

Ventral penile curvature is a key factor in determining the surgical approach to proximal hypospadias repair. However, there is limited evidence regarding the efficacy and long-term effects of the procedures used to address curvature. This study aimed to evaluate the effects of urethral plate transection alone with tissue traction therapy on penile curvature in two-stage repair of proximal hypospadias.

MATERIAL AND METHODS

This was a prospective study of primary hypospadias patients who underwent a two-stage repair with urethral plate transection as the sole straightening procedure. After stage 1, taping was applied as tissue traction therapy and continued until stage 2. Penile curvature was measured using a goniometer under artificial erection before and immediately after urethral plate transection and during the second stage of repair. The primary focus of this investigation is the angle of curvature after 6-month taping.

RESULTS

The study included 46 patients with a median age of 13 months at the start of treatment. The median angle of penile ventral curvature was 70° after degloving, 60° after urethral plate transection, and 0° during the second stage of repair. Full correction of ventral curvature was achieved in 42 patients (91 %).

DISCUSSION

This publication is the first of its kind to propose taping as a method for penile traction therapy in hypospadias. The study reveals that penile ventral lengthening can be achieved through tissue traction therapy following UP transection alone. These findings challenge the current consensus that complete straightening of the penis in the first stage is necessary to prevent recurrent curvature and that ventral lengthening is required to correct corporal disproportion. However, further validation and long-term data are needed to definitively confirm the effectiveness of tissue traction therapy after urethral plate transection.

CONCLUSIONS

This study demonstrated significant resolution rate of penile ventral curvature in proximal hypospadias following urethral plate transection alone with taping. Long-term follow-up studies are needed to confirm the sustainability of the results through puberty.

Conservative treatment of Peyronie's disease: a guide

PURPOSE

To review the literature on the topic, to suggest a common line of treatment applicable across a wide community of specialists, and to contribute in maintaining the high level of interest in this disease.

METHODS

A comprehensive and exhaustive review of the literature was performed, identifying hundreds of articles on the topic.

RESULTS

Peyronie's disease is a condition that has been recognized, studied, and treated for centuries; despite this, if one excludes surgery in cases in which the deformity is stable, no clear treatment (or line of treatment) is available for complete relief of signs and symptoms. Treatment options were divided into local, oral, and injection therapy, and a wide variety of drugs, remedies, and options were identified.

CONCLUSIONS

Low-intensity extracorporeal shock wave therapy, vacuum therapy, penile traction therapy, phosphodiesterase type 5 inhibitors, hyaluronic acid, and collagenase of Clostridium histolyticum may be recommended only in specific contexts. Further studies on individual options or potential combinations are required.

The 100 most-cited publications on Peyronie's disease: a bibliometric analysis and visualization study

This study aimed to summarize the characteristics of the top 100 most-cited publications on Peyronie's disease (PD) research and to analyse past and current research hotspots and trends. The SCI-E database of the Web of Science Core Collection (WoSCC) provided us with the top 100 most-cited publications in PD research, from which we took the following information: general trend of publication, year of publication, nation/region, institution, journal, author, and keywords. VOSviewer (version 1.6.18) and Excel (version 2016) were used for information analysis. Through a standardized search, we ultimately found 1019 papers in the field of PD research, from which we extracted the 100 articles that had received the highest citations. The articles were published between 1949 and 2016. The United States is a major contributor to PD research (n = 67). The University of California, Los Angeles, was the institution with the largest number of articles (n = 11). These articles were published in 16 journals, with the largest number appearing in the Journal of Urology (n = 47). The author with the most articles was Levine LA (n = 9). Gelbard MK's articles had the highest citation frequency (n = 1158). Erectile dysfunction (n = 19) was the keyword with the highest frequency, indicating that PD-related erectile dysfunction was the leading focus of research in this field. Most of the keywords that have appeared in the past decade are related to the clinical treatment of PD. Therefore, we believe that improving patients' erectile function to the greatest extent in clinical treatment is the frontier and hot spot of future research.

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.

Role of Oxidative Stress in Peyronie's Disease: Biochemical Evidence and Experiences of Treatment with Antioxidants

BACKGROUND

Peyronie's disease (PD) is a chronic inflammatory condition affecting adult males, involving the tunica albuginea of the corpora cavernosa of the penis. PD is frequently associated with penile pain, erectile dysfunction, and a secondary anxious-depressive state. The etiology of PD has not yet been completely elucidated, but local injury is generally recognized to be a triggering factor. It has also been widely proven that oxidative stress is an essential, decisive component in all inflammatory processes, whether acute or chronic. Current conservative medical treatment comprises oral substances, penile injections, and physical therapy.

AIM

This article intends to show how antioxidant therapy is able to interfere with the pathogenetic mechanisms of the disease.

METHOD

This article consists of a synthetic narrative review of the current scientific literature on antioxidant therapy for this disease.

RESULTS

The good results of the antioxidant treatment described above also prove that the doses used were adequate and the concentrations of the substances employed did not exceed the threshold at which they might have interacted negatively with the mechanisms of the redox regulation of tissue.

CONCLUSIONS

We believe new, randomized, controlled studies are needed to confirm the efficacy of treatment with antioxidants. However, we consider the experiences of antioxidant treatment which can already be found in the literature useful for the clinical practice of urologists in the treatment of this chronic inflammatory disease.

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.

Assessment of Conservative Combination Therapies for Active and Stable Peyronie's Disease: A Systematic Review and Meta-analysis

CONTEXT

In patients with Peyronie's disease (PD), oral, injected, or topical agents provide limited efficacy. In this setting, combination of two or more conservative treatments may improve symptoms further.

OBJECTIVE

To explore the effects of available conservative combination therapies for active and stable PD through a systematic review and meta-analysis.

EVIDENCE ACQUISITION

We searched multiple databases and sources of gray literature until June 2021. We included randomized or observational comparative studies assessing any conservative combination therapies for PD. We undertook a random-effect meta-analysis when at least two studies employed the same treatment modality (PROSPERO: CRD42021224517).

EVIDENCE SYNTHESIS

Overall, 13 studies on active PD and ten on stable PD (1962 participants) were included. Most included studies raised methodological concerns. In patients with active or stable PD, the available evidence is inconclusive to support the use of any combination treatment modality, such as intralesional verapamil injections, antioxidants, and other oral, injected, or topical agents. Based on data availability, we performed a meta-analysis to compare the effect of collagenase Clostridium histolyticum (CCH) plus adjunctive mechanical therapies (penile traction or vacuum pump) versus CCH monotherapy on penile curvature and length in patients with stable PD. CCH and adjunctive mechanical therapies resulted in an additional decrease of 0.3° in penile curvature (95% confidence interval [CI]: -3.97 to 4.49, I² = 0%) and in an increase of 0.5 cm in penile length (95% CI: -0.32 to 1.4, I² = 70%) compared with CCH monotherapy.

CONCLUSIONS

The available combination treatment modalities, including the addition of adjunctive mechanical therapies to CCH, do not improve symptoms further compared with monotherapy and should not be implemented in patients with active or stable PD. Further high-quality randomized trials combining only recommended treatments are mandatory.

PATIENT SUMMARY

Despite the interest in and optimism for combination treatment modalities, the road to an effective conservative therapy for Peyronie's disease still seems long.

Case report: Kinetics of human leukocyte antigen receptor HLA-DR during liver injury induced by potassium para-aminobenzoate as assessed for causality using the updated RUCAM

Potassium para-aminobenzoate (POTABA) is used to treat Peyronie’s disease by decreasing fibrosis and plaque size progression. Among potential side effects, drug-induced liver injury (DILI) attributed to POTABA administration has been reported in a few cases and inferred to immune hypersensitivity. In the present case, we investigated clinical, biochemical, and serological features as well as searched for non-drug-related causes, and applied the updated Roussel Uclaf Causality Assessment Method (RUCAM) confirming a highly probable causality of POTABA-induced liver injury. Moreover, we here observed specific activated CD3+ T lymphocytes during the acute phase of liver injury by monitoring of human leukocyte antigen receptor (HLA-DR) expression. Furthermore, improvement of biochemical markers of liver injury after POTABA withdrawal was associated with a rapid decline of CD3+ HLA-DR+ immune cells. In contrast, CD14+ monocytes expressing HLA-DR remained stable during recovery from liver injury. These observations implicate a specific involvement of activated T lymphocytes in liver injury mediated by POTABA. Clinicians should be aware of POTABA-induced liver injury, and measurement of activated immune cells by assessment of HLA-DR could provide pathomechanistic insights enabling biomonitoring of recovery from DILI.

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.

Pharmacotherapy in Peyronie's disease: a state-of-the-art review on established contemporary and emerging drugs

INTRODUCTION

Current clinical guidelines on Peyronie's disease (PD) advocate non-surgical treatment options as the first-line therapy despite inconsistent clinical outcomes when compared to definitive penile reconstructive surgery.

AREAS COVERED

This article examines the current understanding of established contemporary and emerging pharmacotherapies for PD. Emphasis has been placed on published clinical studies on drugs in the last 10 years.

EXPERT OPINION

Published studies have shown that combination therapy is likely more effective than monotherapy. Combined treatment modalities involving various oral and/or intralesional pharmacotherapies together with mechanical devices or clinical psychosexual therapy may provide additional or synergistic benefits for PD patients. A multidisciplinary approach coupled with more novel targets for pharmacological intervention could deliver a more effective treatment paradigm to prevent or at least delay the need for definitive penile reconstructive surgery. Drugs targeting the inhibition of TGF-β1 pathway and myofibroblast transformation are of great interest and studies into next-generation genetic sequencing and transcriptional biomarker regulatory pathways in PD will provide useful insights into the pathophysiology of PD, and assist the development of future regenerative technology including cellular-based therapies to target various anti-fibrotic molecular mechanisms and the potential to be integrated into existing treatment armamentarium for PD.

Emerging Roles of Penile Traction Therapy and Vacuum Erectile Devices

INTRODUCTION

Penile traction therapy (PTT) and vacuum erection devices (VED) are nonsurgical conservative treatment options that have been used in the treatment of various urologic and sexual disorders such as Peyronie's Disease (PD) and Erectile Dysfunction (ED). Recently expanded uses for these therapies now include penile lengthening and with surgical interventions such as penile prosthesis surgery (PPS) and radical prostatectomy (RP). These devices can be used as both monotherapy or combination therapy.

OBJECTIVES

To review the indications and clinical studies for PTT and VED.

METHODS

A literature search was conducted using PubMed to identify relevant studies addressing PTT, VED, and their indications. Searched terms included penile traction therapy, penile traction device, vacuum erection device, Peyronie's disease, penile prosthesis, radical prostatectomy, subjectively small penis, penile lengthening, erectile dysfunction.

RESULTS

PTT with dynamic traction devices has shown favorable benefits for PD in many studies. The benefits of VED for PD cannot be confirmed due to limited studies with poor quality. In posterior urethroplasty, VED shows promise postoperatively, with additional trials also needed. In PPS, both PTT and VED have had positive findings in pre- and postoperative treatment. In RP patients, VED use has had positive outcomes while new literature shows beneficial effects of dynamic PTT and provides a basis for future studies. VED use does not show great benefit in patients with small penis, however PTT does have some positive findings. In ED, VED has a history of successful use and PTT has promising new data available.

CONCLUSION

PTT and VED have been utilized in urologic and sexual conditions with various success. Several promising areas utilizing both PTT and VED are being studied, however, more research needs to be done in these areas prior to becoming a standard treatment. Mehr J, Santarelli S, Green TP, et al. Emerging Roles of Penile Traction Therapy and Vacuum Erectile Devices. Sex Med Rev 2021;XX:XXX-XXX.

Indications and characteristics of penile traction and vacuum erection devices

A variety of devices are available for the management of patients with erectile dysfunction, Peyronie's disease, penile dysmorphophobia, for support before and after penile prosthesis insertion, and after radical prostatectomy. Traction devices include, but are not limited to, Penimaster PRO (MSP Concept, Berlin, Germany), Andropenis and Andropeyronie (Andromedical, Madrid, Spain), and the Restorex (PathRight Medical, Plymouth, USA). The other type of devices are vacuum devices such the Osbon ErecAid (Timm Medical, MN, USA). Different devices are optimal for different clinical applications, and robust and contemporary clinical data show a variety of strengths and weaknesses for each device. Research currently favours the use of traction devices for improvement of penile curvature and erectile function in patients with Peyronie's disease compared with vacuum devices; Penimaster Pro and Restorex have been shown to be associated with the best outcomes in this indication. Vacuum devices are favoured for treatment of erectile dysfunction and penile length loss after radical prostatectomy; the Osbon ErecAid is the most well-studied device for this indication. Research into other uses of vacuum and traction devices, such as for penile dysmorphophobia or before and after penile prosthesis, is very limited. Compliance, cost and availability remain substantial challenges, and further high-quality evidence is required to clarify the role of traction devices in urology and sexual medicine.

Extracorporeal Shockwave Therapy in Peyronie's Disease: Systematic Review and Meta-Analysis

BACKGROUND

Peyronie's disease (PD) is associated with penile pain, deviation, and sexual dysfunction. Up till now, there is no conservative standard treatment for PD. However, the role of Extracorporeal Shock Wave Therapy (ESWT) is gaining increasing interest.

AIM

To evaluate the effect of ESWT on penile deviation, plaque size, erectile function, pain scale, and the rate of complications in PD patients.

METHODS

PubMed database was searched for articles published from January 2000 to November 2020, using related keywords and including randomized controlled trials (RCTs) only. Meta-analysis and forest plots were carried out using RevMan, and outcomes were reviewed by 2 authors independently. PRISMA guidelines were used in this article to achieve the quantitative and qualitative synthesis of data.

OUTCOMES

Changes in penile deviation, plaque size, erectile function, pain scale, and the rate of ESWT related complications.

RESULTS

The search yielded 73 articles. Three RCTs, including 117 patients in the ESWT group and 121 patients in the placebo group, were reviewed. ESWT is associated with reduction in plaque size (OR = 2.59, 95% CI (1.15-5.85), P= .02). No significant difference in reduction of penile deviation angle or rate of bruises were detected in post ESWT group when compared to placebo. No evidence was found to show an effect of ESWT on erectile function or pain scale.

CLINICAL IMPLICATIONS

Based on the available RCTs, ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance.

STRENGTHS & LIMITATIONS

RCTs used different metrics to report the same outcome. Missed data were imputed to match the requirements of meta-analysis. However, there is still much data that cannot be estimated.

CONCLUSION

The current data suggest that ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance, and further studies are required to confirm findings. Bakr AM, El-Sakka A. Extracorporeal Shockwave Therapy in Peyronie's Disease: Systematic Review and Meta-Analysis. J Sex Med 2021;18:1705-1714.

The Use of Penile Traction Devices for Peyronie's Disease: Position Statements from the European Society for Sexual Medicine

INTRODUCTION

Penile traction therapy (PTT) aims to non-surgically reduce curvature, enhance girth, and recover lost length. Available clinical practice guidelines however lack clear recommendations regarding their use.

AIM

To present a comprehensive review and recommendation regarding the available evidence to the use of PTT in Peyronie's disease (PD).

METHODS

A systematic literature search was performed on Pubmed and Medline for relevant studies from all times until 2019. Studies of PTT (monotherapy and in combination) in patients with PD with any documented degree of curvature and in either the acute or chronic phase of the disease were included. Full texts not published in English language were excluded.

MAIN OUTCOMES MEASURES

Several scenarios, including preclinical data have been investigated. For each topic covered evidence was analyzed and expert opinion was stated.

RESULTS

The paucity of high-level studies precluded any strong recommendations, however, specific statements on this topic, summarizing the ESSM position, were provided. The available data about the use of PTT in PD are still poor, and the impact of this therapy for the treatment of PD has not been clearly stablished. Available data in the clinical setting are still poor, and the impact of these devices on PD evolution has not been clearly established.

CONCLUSION

PTT seems to be a valid treatment option for PD, although there is not enough evidence to give any definitive recommendation in any clinical scenario. García-Gómez B, Aversa A, Alonso-Isa M et al. The Use of Penile Traction Devices for Peyronie's Disease: Position Statements from the European Society for Sexual Medicine. Sex Med 2021;9:100387.

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.

[French Urological Association (AFU) guidelines for Peyronie's disease assessment and treatment]

INTRODUCTION

Peyronie's disease is a common cause for consultation in urology. Many controversies surround its treatment. No French Guidelines have been published so far. The Committee of Andrology and Sexual Medicine of the French Association of Urology therefore offers a series of evidence-based recommendations.

MATERIALS AND METHODS

These recommendations are made according to the ADAPTE method, based on European (EAU, ESSM), American (AUA, ISSM) and Canadian (CAU) recommendations, integrating French specificities due to the availability of treatments, and an update of the recent bibliography.

RESULTS

The assessment of the disease is clinical. Patients with functional impairment or significant psychological repercussions may be offered treatment. The benefits and drawbacks of each treatment should be explained to the patient. Regarding non-surgical treatments, no available treatment has market authorization in France. Vitamin E is not recommended. Analgesic (oral or low-intensity shock waves) or proerectile treatments may be offered as needed, as well as traction therapy. Due to the unavailability of collagenase injections, verapamil injections may be offered. Surgical treatments are to be considered in the stabilized phase of the disease, and consist of performing a plication, an incision-graft or the placement of a penile implant according to the patient's wishes, the curvature and the penis size, as well as erectile function. Combination treatments can be offered.

CONCLUSION

The management of Peyronie's disease is complex, and the levels of evidence for treatments are generally low. The success of treatment will depend on the quality of the initial assessment, the patient's information and understanding of the expected effects, and the practitioner's experience.

Peyronie's disease: pharmacological treatments and limitations

Introduction: Peyronie's disease (PD) is a disorder of the tunica albuginea from disordered and excessive deposition of collagen resulting in a palpable scar, pain, erect penile deformity and erectile dysfunction that significantly impacts patients both physically and emotionally.Areas Covered: Several treatment options have been described for PD, including shockwave therapy, traction therapy, both oral and intralesional pharmacological options, and surgery. This review seeks to examine the data for different types of non-surgical treatments for PD. We review how various treatment modalities impact several relevant clinical endpoints for Peyronie's disease, including effects on pain, penile curvature, plaque formation, and erectile function. We performed a literature search using PubMed and SCOPUS while referencing AUA, EAU, and CUA guidelines for management of Peyronie's Disease for studies published 1980-2020.Expert opinion: Intralesional collagenase injections have the strongest evidence and are the only FDA approved intralesional treatment for PD. Penile traction therapy (PTT) is low risk and may be beneficial in patients willing to invest significant time using the devices. Furthermore, oral combination therapy with other modalities may provide some benefit. Further investigation is required to better understand pathophysiology of PD and clarify the therapeutic utility of existing treatments, potentially with a multimodal strategy.

Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review

Peyronie's disease is a common condition resulting in penile deformity, psychological bother, and sexual dysfunction. Erectile dysfunction is one common comorbid condition seen in men with Peyronie's disease, and its presence significantly impacts treatment considerations. In a man with Peyronie's disease and significant erectile dysfunction who desires the most reliable treatment, penile prosthesis placement should be strongly considered. In some instances, such as those patients with relatively mild curvature, prosthesis placement alone may result in adequate straightening. However, many patients will require additional straightening maneuvers such as manual modeling, penile plication, and tunica albuginea incision with or without grafting. For patients with severe penile shortening, penile length restoration techniques may also be considered. Herein, we provide a comprehensive clinical review of penile prosthesis placement in men with Peyronie's disease. Specifically, we discuss preoperative indications, intraoperative considerations, adjunctive straightening maneuvers, and postoperative outcomes.

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.

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.

Non-invasive and surgical penile enhancement interventions for aesthetic or therapeutic purposes: a systematic review

OBJECTIVE

To systematically review the literature in order to investigate the efficacy and safety of surgical and non-invasive penile enhancement procedures for aesthetic and therapeutic purposes.

METHODS

A systematic search for papers investigating penile enhancement procedures was performed using the MEDLINE database. Articles published from January 2010 to December 2019, written in English, including >10 cases, and reporting objective length and/or girth outcomes, were included. Studies without primary data and conference abstracts were excluded. The main outcome measure was objective length and/or girth improvement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Out of 220 unique records, a total of 57 were reviewed. Eighteen studies assessed interventions for penile enhancement in 1764 healthy men complaining of small penis. Thirty-nine studies investigated 2587 men with concomitant pathologies consisting mostly of Peyronie's disease and erectile dysfunction. Twenty-five studies evaluated non-invasive interventions and 32 studies assessed surgical interventions, for a total of 2192 and 2159 men, respectively. Non-invasive interventions, including traction therapies and injection of fillers, were safe and mostly efficacious, whereas surgical interventions were associated with minor complications and mostly increased penile dimensions and/or corrected penile curvature. Overall, the quality of studies was low, and standardized criteria to evaluate and report efficacy and safety of procedures, as well as patient satisfaction, were missing.

CONCLUSION

The quality of the studies on penile enhancement procedures published in the last decade is still low. This prevents us from establishing recommendations based on scientific evidence regarding the efficacy and safety of interventions that are performed to increase the penis size for aesthetic or therapeutic indications.

Prevalence, Risk Factors, and Erectile Dysfunction Associated With Peyronie's Disease Among Men Seeking Urological Care

INTRODUCTION

Peyronie's disease (PD) is a connective tissue disorder of the penis characterized by an abnormality in collagen structure of penile tunica albuginea.

AIM

We sought to investigate the prevalence, risk factors, and the relationship between erectile dysfunction (ED) and PD in male patients aged 30-80 years seeking urological care.

METHODS

This is a cross-sectional study using data collected from October 2016 to October 2017 in an outpatient clinic associated with the Brazilian Public Health System. All men aged 30 to 80 years were invited to participate. Data collected were related to the clinical history and sexual habits of patients using the International Index of Erectile Function, in addition to the physical examination of the penis and laboratory parameters.

MAIN OUTCOME MEASURE

Descriptive statistics and multivariate logistic regression models tested the prevalence, risk factors, and the relationship between ED and PD in male patients.

RESULTS

The study included 656 individuals, who were distributed as per age, marital status, race, educational level, and income. Of these participants, 86 (13.11%) presented with fibrous plaques compatible with PD at the physical examination. Among the risk factors evaluated, PD was associated with diabetes, smoking, and obesity in 43.02, 64.17, and 26.74% of patients, respectively. The presence of penile plaques compatible with PD was more prevalent in men with ED, history of penile trauma, and complaint of penile deformity. There was a higher prevalence of plaques in the distal penis.

CONCLUSION

The PD among the studied population was associated with risk factors such as diabetes, smoking, and obesity. Other clinical characteristics, such as history of penile trauma, penile deformity, and ED, were reported in patients with PD. There was a higher prevalence of plaques in the distal penis, specifically in the corona of the glans penis. The prevalence of PD was different from that in the published literature, our results show that numbers thus more studies are needed. Segundo A, Glina S. Prevalence, Risk Factors, and Erectile Dysfunction Associated With Peyronie's Disease Among Men Seeking Urological Care. Sex Med 2020;8:230-236.

Recent advances in managing Peyronie's disease

Treating men with Peyronie's disease remains a challenging problem facing clinicians working across urology and sexual medicine fields. Patients can often be left disappointed by current treatment paradigms, and an overall lack of suitable molecular targets has limited the options for novel, effective medical therapy. Managing men with Peyronie's disease often involves careful counselling alongside multifaceted and possible combination treatments to help improve symptoms whilst ameliorating potential side effects of therapy. We review the latest medical literature and evidence in the contemporary management of Peyronie's disease.

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.

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.

A modern review of penile traction monotherapy and combination therapy for the treatment of peyronie's disease

Peyronie's disease (PD)-related penile deformity is managed with multiple treatment modalities including oral medications, intralesional injections, and surgery. Penile traction therapy (PTT) is one such modality with purported benefits, albeit with notable differences in the characteristics of available traction devices and published study protocols. We provide a comprehensive review of the available data supporting PTT for PD treatment. We performed a rigorous database search to identify all studies pertaining to PTT for the treatment of PD through November 2019. Seventeen trials explored use of PTT as monotherapy or in combination with surgical or nonsurgical treatment, using over five different commercially available devices. All devices were well tolerated, although compliance and daily duration of use were highly variable. PTT resulted in variable improvements in stretched penile length and penile curvature, depending on study protocol, patient population, and device. PTT appears to be a safe and well-tolerated treatment for PD as monotherapy or in combination with other nonsurgical and surgical treatments, and for men in both the acute and chronic phases. Further studies are needed to compare available devices, evaluate device characteristics associated with treatment success, differentiate outcomes in acute vs. chronic PD populations, and determine the optimal duration of use.

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.

Long-term patient-reported outcomes in men with Peyronie's disease undergoing nonsurgical and nonintralesional injection management

Peyronie's disease (PD) has a negative impact on overall quality of life for many patients and their partners. There is a significant portion of patients who elect noninvasive therapy and in this scenario we have little data with which to counsel patients. We aim to evaluate long-term patient-reported outcomes in a cohort of men with PD who elected conservative treatment. We identified all males with a diagnosis of PD evaluated at our institution by a single provider between May 2012 and January 2018. We excluded men who were <18 years old or had undergone surgical or intralesional injection (ILI) treatments. A PD-specific questionnaire was sent to those who met our inclusion criteria. 88/514 patients completed the survey and met the inclusion criteria. Penile curvature subjectively improved in 49%, remained stable in 34%, and worsened in 17%. Penile shortening was reported in 89% of patients. Penile shortening subjectively improved in 27%, remained stable in 59%, and worsened in 14%. Roughly 60% reported worsened intercourse satisfaction and erectile function. 60% reported that PD had negatively impacted their self-esteem and 69% felt that PD negatively impacted their sexual partner. Patients who utilized penile traction therapy (PTT) were significantly more likely to report improvements in penile curvature, shortening, and ability to engage in penetrative intercourse. Our survey provides important data on patient-reported outcomes in men with PD electing nonsurgical and non-ILI interventions. Although 49% of men noted at least a mild subjective improvement in their curvature over time, a majority had declining erectile function, decreased intercourse satisfaction, and psychosocial distress. These data can be used when counseling patients with a new diagnosis of PD who are considering treatment options.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Evaluation of Oral Pentoxifylline, Colchicine, and Penile Traction for the Management of Peyronie's Disease

Introduction

Currently, there are several treatment options for Peyronie disease (PD). Although surgical interventions have better reported outcomes than conservative therapy, surgery is not suitable for all patients with PD. Therefore, oral therapy for PD is still a frequently used treatment due to low cost, convenience and limited side effects. However, current literature on the efficacy of oral therapy in PD is inconclusive. Pentoxifylline and colchicine have both shown some promise though further studies are required to confirm their effectiveness.

Aim

The aim of this study was to assess the efficacy of oral therapy for PD, including pentoxifylline and colchicine, coupled with the Andropenis penile traction therapy (PTT) extender on degree of penile curvature and plaque size.

Methods

Between March 2015 and June 2018, a prospectively collected database for patients receiving oral therapy for PD (pentoxifylline and/or colchicine) was reviewed.

Main Outcome Measure

Collected data variables were compared at baseline and after 6 months of treatment, including degree of curvature, plaque size, and penile Doppler ultrasound parameters (peak systolic velocity, minimum diastolic velocity, and pulsatility index). PTT was applied by the patient for a total of 1 hour per day for 6 months.

Results

A total of 46 patients were involved in this study. Mean age was 56 ± 10 years. There was a significant decrease in the degree of penile curvature after 6 months (55.8º ± 20º vs 41.4º ± 20.8º; P = .03). Likewise, the plaque size decreased significantly from 5.42 ± 2.7 to 2.42 ± 1.71 cm²; P = .0001. There was a significant increase in the peak systolic velocity from 29.8 ± 10.02 to 38.2 ± 11cm/sec; P = .02, whereas no statistically significant difference could be detected regarding end diastolic velocity (M = 0.56 ± 3.1 vs 1.59; P = .415) or pulsatility index (M_diff = 0.03; CI = -0.06 to 0.12; P = .473). Furthermore, there was no statistically significant difference in medication type of pentoxifylline or colchicine (M_diff = 17.23; CI = -3.31 to 37.77; P = .09).

Conclusion

Altogether, pentoxifylline and colchicine, taken with concomitant PTT, present a potentially convenient, low cost, and effective treatment for penile curvature and plaque resulting from PD. Prospective randomized trials are still required for better evaluation of the course of PD with patients undergoing conservative management.

Ibrahim A, Gazzard L, Alharbi M, et al. Evaluation of Oral Pentoxifylline, Colchicine, and Penile Traction for the Management of Peyronie’s Disease. Sex Med 2019;7:459–463.

Clinical characteristics and surgical outcomes in men undergoing tunica albuginea plication for congenital penile curvature who present with worsening penile deformity

PURPOSE

Men with congenital penile curvature (CPC) can develop new onset worsening of their lifelong curvature. We sought to evaluate clinical characteristics and postoperative outcomes after tunica albuginea plication (TAP) in patients presenting with CPC who reported new onset worsened curvature (CPC-WC), and compare these with patients reporting stable lifelong curve ("CPC-only").

METHODS

A retrospective review of demographics, history/exam findings, and postoperative outcomes for patients with CPC who underwent TAP from 2012 to 2018 was performed. Patients were differentiated based on whether or not they reported new onset worsening of their penile curvature preoperatively (CPC-WC versus CPC only). Statistical analysis was performed to identify differences in clinical characteristics and postoperative outcomes after TAP.

RESULTS

60 patients were included [CPC only (n = 39) and CPC-WC (n = 21)]. Mean curvature was 62° (SD 23). CPC-WC patients were older [median 34 years (IQR 27:52) versus 24 years (IQR 20:34); p = 0.004], and more likely to report penile shortening and psychological bother (p < 0.05). On physical examination, CPC-WCs were more likely to have a discrete palpable tunical scar and diminished penile elasticity (p ≤ 0.0002). With median follow up of 12 months, satisfactory straightening with TAP was reported in 56/60 patients (93%) including 35/39 (90%) CPC only and 21/21 (100%) CPC-WC.

CONCLUSIONS

In men undergoing TAP for CPC, we found that 35% reported new onset worsening of their original curvature preoperatively. These patients were older and more likely to report penile shortening or exhibit palpable tunical scarring with decreased elasticity on examination compared to those with lifelong stable curvature. Regardless, TAP resulted in satisfactory penile straightening in the majority of patients.

Ten-year experience with multimodal treatment for acute phase Peyronie's disease: A real life clinical report

OBJECTIVES

To present our experience with multimodal therapy for Peyronie's disease.

METHODS

Retrospective data were collected since 2008 to 2017. The following features were evaluated at baseline and after treatment: age, duration of disease, erectile function, erected penile curvature, and stretched penile length. All patients were offered the same protocol including: 12 intralesional verapamil injections, oral therapy (OT) ?L-arginine 2g once and pentoxifylline 400mg 3 times a day for 6 months?, and penile traction therapy. The adherence to each of the 3 components of multimodal treatment was evaluated.

RESULTS

One hundred and seventy-seven individuals were considered. Depending on the grade of adherence our survey was divided into 3 groups. Group 1: patients who only completed OT; group 2: men who accomplished OT and intralesional verapamil injections; group 3: patients who completed the entire protocol. Seventy-six, 45 and 56 men were assigned to group 1, 2 and 3 respectively. The mean age at the diagnosis was 59±8.4, 59.1±5.9 and 54.2±4.8 years, while the mean duration of the disease was 6.3±3.4, 4.8±2.9 and 3.9±3.1 months in group 1, 2 and 3. The erected penile curvature before and after treatment was 24.2±9 and 23.7±8.9° in group 1 (P<.36); 25.4±16.8 and 24.1±13.6° in group 2 (P<.34), and 34.3±17.9 and 26.1±17.2° in group 3 (P<.001).

CONCLUSIONS

OT alone was successful to block the progression of the disease. The add of intralesional verapamil injections to OT brought only mild improvements. The complete protocol significantly reduced erected penile curvature and improved erectile function.

Additional procedures performed at time of penile prosthesis implantation: a review of current literature

Penile prosthesis implantation for treatment of medical refractory erectile dysfunction remains the gold standard. However, some men have additional pathology present such as Peyronie's Disease, penile shortening, penoscrotal webbing, buried penis or other penoscrotal anatomical abnormalities that may be addressed at the time of prosthesis implantation. Although several techniques are described, there remains a lack of data regarding the outcomes. We sought to identify the results of available literature regarding the additional procedures performed at the time of penile prosthesis implantation that provide defined surgical outcomes rather than merely describe surgical techniques. Surgical outcomes to procedures provide more realistic clinical outcome for readers than simply the description of novel techniques or expert opinions. We performed a review of the MEDLINE database to identify additional procedures performed in conjunction with penile prosthesis placement. Many procedures are described in review articles, however, with limited data regarding their outcomes. The included articles must describe additional procedures performed in conjunction with penile prosthesis placement. Perioperative office techniques and management were included if it changed the surgical technique. All abstracts obtained through search criteria were reviewed. Only articles written in English, on human subjects with documented surgical results and relevant articles were included in this study. After a thorough literature search, a total of 24 articles were identified. Penile lengthening procedures at the time of penile prosthesis comprise most of the literature on this subject. Lengthening procedures are as simple as Peyronie's plaque excision and grafting to complex sliding and lengthening procedures requiring complete neurovascular bundle and partial urethral mobilization. Additionally, aggressive cylinder sizing and prolonged postoperative cycling at home are also described. Glanulopexy may be necessary when malpositioning of the glans is present. Other options such as scrotoplasty are also available options for those patients with scrotal webs. Notably there is a paucity of published literature regarding girth enhancement, buried penis repair, hernia repair, and vasectomy at time of penile prosthesis placement. There are numerous procedures that can be performed in the same operative setting as penile prosthesis. Although the procedures do have a common goal to provide optimal postoperative natural appearance, length, straightness, girth and function, the techniques employed must be tailored to each patient as there is not a one-procedure fits all in this patient population.

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.

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

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

Penile traction therapy with the new device 'Penimaster PRO' is effective and safe in the stable phase of Peyronie's disease: a controlled multicentre study

OBJECTIVES

To evaluate the efficacy and safety of a new penile traction device (PTD), 'Penimaster PRO', in a group of patients with stable Peyronie's disease (PD) compared with a non-intervention group in a multicentre study.

MATERIAL AND METHODS

A total of 93 patients with chronic stable PD (without erectile dysfunction, with no significant pain, and with a unidirectional curvature of at least 45° being stable for > 3 months) were recruited and followed for a 12-week period. Of these patients, 47 were randomly assigned to the Penimaster PRO group (PG) and 46 to the non-intervention group (NIG). Patients were asked to apply the PTD 3-8 h a day for 12 consecutive weeks, with specific instructions regarding the progressive increase of traction force applied to the penis over time. The primary outcome of the study was the change in the degree of curvature measured in the fully erect state after intracavernosal injection of alprostadil at baseline, 1, 2 and 3 months. Other variables, such as the type of curvature, stretched penile length (SPL), Peyronie's Disease Questionnaire (PDQ) scores, erectile function domain of the International Index of Erectile function (IIEF-EF) score and adverse events (AEs) were also assessed in each visit.

RESULTS

Forty-one patients in the PG and 39 in the NIG completed the study. There was an overall reduction in curvature of 31.2° (P < 0.001) at 12 weeks compared to baseline in the PG, representing a 41.1% improvement from baseline, which significantly correlated with the number of daily hours the device was applied in a dose-dependent manner. Those patients using the device < 4 h/day experienced a reduction of 15°-25° (mean 19.7°, 28.8% improvement; P < 0.05), while patients using the device > 6 h/day experienced greater curvature reduction, ranging from 20° to 50° (mean of 38.4°, 51.4% improvement; P < 0.001). In contrast, no significant changes in curvature were observed in the NIG. Furthermore, SPL increased significantly in the PG compared to baseline and compared with the NIG, ranging from 0.5 to 3.0 cm (mean 1.8 cm; P < 0.05). The IIEF-EF score also improved in patients in the PG (by a mean of 5 points). Mild AEs occurred in 43% of patients, such as local discomfort and glans numbness.

CONCLUSION

The use of the Penimaster PRO PTD, a non-invasive treatment, should be offered to patients with stable PD for 3 consecutive months before performing any corrective surgery, as this provided a significant reduction in the curvature, an increase in penile length and a significant improvement of the symptoms and bother induced by PD.

Devices for penile traction: the long and winding road to treating Peyronie's disease

INTRODUCTION

Penile traction therapy (PTT) is increasingly being recognized as a viable nonsurgical approach to Peyronie's disease (PD). The goal of this article is to review the current literature on PTT with attention to traction protocols, devices, and outcomes.

AREAS COVERED

Literature on the pathophysiology of PD, PTT as primary and adjunctive treatment for PD, perioperative use of PTT, and vacuum erection devices are all reviewed. Pertinent literature was obtained from the PubMed database. The key words 'penile traction,' 'mechanotransduction,' and 'Peyronie's disease' were searched and results were narrowed down based on relevance to the review.

EXPERT COMMENTARY

PTT appears beneficial but the true magnitude of effect is difficult to discern. Most studies are not randomized, have small sample sizes, lack control arms, or have varying traction protocols. Patient compliance is critical and new devices and traction protocols are needed to maximize the benefit of PTT.

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.

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.

Rationale of combination therapy with antioxidants in medical management of Peyronie's disease: results of clinical application

Peyronie's disease (PD) is a connective tissue disorder involving the tunica albuginea of the corpora cavernosa of the penis. We have published several studies describing a "combined therapy" for PD patients, but the present study aims to clearly demonstrate how the association between various antioxidants in PD treatment can significantly increase the likelihood of therapeutic success. We used the following substances: silymarin, ginkgo biloba, vitamin E, bilberry, topical diclofenac sodium, and pentoxifylline (PTX). We analyzed the therapeutic impact and possible side effects of one or more antioxidants in patients with early-stage PD. To clearly prove that it is possible to achieve better results when combining more than one agent, we designed this study with five treatment groups, corresponding, respectively, to the administration of a single oral antioxidant; two oral antioxidants; three oral antioxidants; five oral antioxidants + local diclofenac; and five oral antioxidants + local diclofenac + PTX by perilesional injection. One hundred and twenty patients were assigned to five groups of treatment designed according to the abovementioned study aim. Outcomes after 6 months of treatment showed that combined antioxidant therapy is effective in treating PD. Statistical analysis showed significant differences between the treatment groups with regard to: improvement and disappearance of penile pain; percentage of reduction in the volume of penile plaque; reduction in penile curvature; recovery of erectile function in patients with erectile dysfunction; increase in the International Index of Erectile Function score; and reduction of psychosexual impact. Furthermore, we observed that the clinical efficacy of combined therapy is greater when topical use of diclofenac gel and perilesional injection of PTX are added to oral treatment with more than one antioxidant. Although several articles have already been published reporting the effectiveness of combined treatment in PD, this is the first study clearly proving how, as the number of substances used in treatment rises, a proportionally greater therapeutic effect is achieved.