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

Imaging techniques for diagnosing and managing Peyronie disease

Erectile dysfunction (ED) affects up to 50% of men to some degree and has a variety of physiologic and psychologic causes, but many patients do not seek specialist treatment. One cause of ED is Peyronie disease (PD) defined by the presence of fibrotic plaques in the tunica albuginea which cause painful penile contractures. While diagnosing PD relies on clinical history and a focused history and physical exam, adding imaging studies can identify nonpalpable plaques and any underlying vasculogenic ED to tailor the extent of surgical treatment and determine when implantable penile prostheses are beneficial. After briefly reviewing penile anatomy, erectile function, and the clinical features of PD, this paper describes the imaging findings of vasculogenic ED on Doppler ultrasound (US), followed by the imaging appearance of PD on US, computed tomography (CT), and magnetic resonance imaging (MRI) to increase recognition of this disease and show how imaging can be used as a problem-solving tool for treatment planning and evaluating post-surgical complications, especially malfunctioning implanted devices. By increasing the understanding of how imaging can be used for patients with PD with or without vasculogenic ED before and after treatment, radiologists and urologists can collaborate on patient management.

Peyronie's disease response to intralesional collagenase clostridium histolyticum therapy is independent of baseline testosterone

BACKGROUND

Testosterone plays an important role in collagen metabolism, transforming growth factor-β1 expression, and wound healing, which are all critical factors in pathogenesis of Peyronie's disease. Some clinical studies have suggested an association between Peyronie's disease and hypogonadism.

OBJECTIVE

We sought to investigate whether baseline total testosterone levels influence response to intralesional collagenase clostridium histolyticum in Peyronie's disease.

METHODS

A retrospective review of patients receiving collagenase clostridium histolyticum injections with available total testosterone levels within 1 year of initial injection was conducted at a single institution. Baseline demographics, hypogonadal status, total testosterone, number of collagenase clostridium histolyticum cycles, and pre- and post-treatment degrees of curvature were collected. Hypogonadism was defined as total testosterone <300 ng/dL.

RESULTS AND DISCUSSION

Thirty-six men were included with mean age of 58.2 years (SD 10.4) and mean body mass index 26.8 (SD 3.2). The mean total testosterone was 459.2 ng/dL (SD 144.0), and four (11.1%) were hypogonadal. Mean pre-treatment curvature was 47.6°, and mean post-treatment curvature was 27.8°, with mean improvement of 19.9° (40.1%). Hypogonadal status was not significantly associated with more severe curvature, 46.4° among hypogonadal men as to 57.5° among eugonadal men (p = 0.32). On linear regression analysis, total testosterone did not significantly predict improvement in degrees (β = -0.02; R2 = 0.06; p = 0.14) or percent (β = 0.0; R2 = 0.05; p = 0.18). Improvement in neither degrees nor percent differed significantly by hypogonadal status (p = 0.41 and 0.82, respectively). The cycle number did significantly predict greater improvement in curvature on both univariate and multivariate analyses (β = 5.7; R2 = 0.34; p < 0.01).

CONCLUSION

Neither total testosterone nor hypogonadism is associated with a degree of improvement after collagenase clostridium histolyticum treatment.

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.

Multiple courses of intralesional collagenase injections for Peyronie disease: a retrospective analysis

BACKGROUND

In the original clinical trials evaluating intralesional collagenase Clostridium histolyticum for Peyronie disease (PD), treatment protocols were limited to 8 injections.

AIM

We sought to describe our single-center experience with the use of multiple rounds (>8 injections) of intralesional collagenase in patients with PD.

METHODS

We conducted a retrospective analysis of all patients with PD receiving intralesional collagenase injections at our institution from October 2015 through December 2020. Some patients who completed 1 round of treatment elected to undergo additional rounds (16 or 24 injections) based on persistent curvature and presence of penile plaque. Clinical improvement was defined as a 20% reduction in penile curvature from the start of a given round of treatment to the end of that round of treatment. We measured erect penile curvature before and after each round and collected demographics, medical and surgical history, curvature outcomes, and treatment-related adverse events.

OUTCOME

The primary outcome was the reduction in penile curvature after multiple rounds of treatment with intralesional collagenase injections in patients with PD.

RESULTS

A total of 330 patients underwent intralesional collagenase injections for PD, of whom 229 completed at least 8 injections and underwent pre- and posttreatment erect penile goniometry. An overall 42.8% (98/229), 38.6% (22/57), and 12.5% (1/8) of patients achieved clinical improvement after 1 round of therapy (8 injections), 2 rounds (16 injections), and 3 rounds (24 injections), respectively. Mean degree and mean percentage improvement of penile curvature for the start and end of each round of treatment were 8.3° and 16.4% (after 1 round), 7.2° and 16.8% (after 2 rounds), and 3.3° and 8.1% (after 3 rounds). Bruising was the most common complication, with an incidence of at least 50% in each round.

CLINICAL IMPLICATIONS

Knowledge of patient responses to multiple rounds of intralesional collagenase injections may help guide physicians in management and counseling of patients regarding PD treatment options.

STRENGTHS AND LIMITATIONS

This is the first study to evaluate multiple rounds (>8 injections) of intralesional collagenase for PD. Limitations include retrospective analysis and smaller sample size among patients undergoing 3 rounds (24 injections).

CONCLUSION

For patients who did not achieve clinical improvement after 1 round of treatment, an additional round may be beneficial. However, no real improvement was observed for patients undergoing a third round.

Improvement in the ability to have sex in patients with Peyronie's disease treated with Collagenase Clostridium histolyticum

Objective

To describe the results of intralesional Collagenase Clostridium histolyticum (CCH) treatment in patients with Peyronie's disease (PD) in real-world setting. PD is characterized by curvature of the erect penis caused by fibrotic tissue in the tunica albuginea.

Patients and methods

Patients with stable PD and curvature of 30° to 90° were prospectively enrolled. CCH injections were initially given using a scheme of four cycles of two injections within 48-72 h every 6 weeks. Later using a modified scheme of three injections every 4 weeks, combined with a vacuum erection device (VED) twice daily. All patients were requested to take pictures of the erect penis prior to and following treatment, from above and laterally. Curvature was measured by three independent researchers based on the provided pictures using a goniometer. Furthermore, patients filled in the Peyronie Disease Questionnaire-NL (PDQ-NL) and Patient Reported Outcome Measurement (PROM).

The primary outcome was reduction in curvature and the ability to have penetrating sex again. Secondary outcomes include pain scores during injections, changes in PDQ-NL, PROM and complications of CCH treatment.

Results

Sixty-three patients were included, mean age was 56.0 years (range 39-70) and mean reduction in curvature 20.6° (SD 10.2, range 5-49); 74.5% of the patients were able to have penetrating sex again following treatment, compared with 41.2% prior to treatment. According to the PROM questions, sexual improvement was seen in 66.7% of patients. The satisfaction rate was 6.8 (SD 1.8). All patients save two recommend treatment.

Conclusions

Intralesional treatment with CCH in men with PD leads to a mean curvature improvement of 20.6°. Following treatment, 74.5% of men were able to have sexual intercourse and 54.9% of the couples were satisfied with their sex life. No major complications occurred in the patients treated with CCH. CCH is not available in Europe anymore despite good results.

Treatment-related Outcomes for Patients With Atypical Peyronie's Disease Using Xiaflex Injections

OBJECTIVE

To evaluate the efficacy and safety of collagenase Clostridium histolyticum (CCH) for the management of penile deformities in patients presenting with different categories of atypical Peyronie's disease (PD).

METHODS

We conducted a retrospective review of charts of patients who presented to a men's health clinic with atypical PD between October 2016 and June 2019. We included patients in the stable phase of the disease, had completed a penile duplex Doppler ultrasound before any intervention, and proceeded with CCH treatment. Gathered data included patient demographics, treatment details, outcomes, and complications. Outcomes collected were both quantitative (curvature assessments) and qualitative using the symptom bother domain (last 6 questions; Q10 to Q15) of the Peyronie's Disease Questionnaire.

RESULTS

Twenty-one men with stable PD underwent CCH inject therapy after penile duplex Doppler ultrasound. The mean number of injections was 8.4 (standard deviation [SD] = 3.3), and the mean follow-up was 20.5 months (SD = 5.9). The overall mean change in penile curvature was -19.2° ± 8.3°, which corresponded to a -39% ± 13% improvement in curvature (P = .0079). In men who presented with an indentation or hourglass deformity, 11 of 17 (64%) were satisfied and reported subjective improvement in narrowing/indentation after receiving CCH injections. The average composite symptom bother domain of the Peyronie's Disease Questionnaire decreased by 6.7 (P = .0029).

CONCLUSION

Our results suggest that CCH appears to be safe and provide significant clinical improvements in men presenting with atypical PD.