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.

Safety and Efficacy Study of Collagenase Clostridium Histolyticum Applied With an Intensive Protocol in the Treatment of Peyronie's Disease

Introduction

Collagenase clostridium histolyticum (CCH) is a treatment for Peyronie's disease (PD) whose efficacy and safety has been demonstrated using a classic protocol and a shortened protocol.

Aim

To evaluate the efficacy and safety of an even more intense protocol in which a CCH injection is applied for 3 separate cycles of 1 week.

Methods

Prospective, nonrandomized, clinical study of a cohort of 13 patients with PD and non-ventral curvatures, between 30 and 90 degrees and with stable disease were included. Under local anesthesia, 0.9 mg of CCH is infiltrated in 3 parallel and equidistant transverse bands across the plaque in 3 sessions separated by 1 week. Between sessions the patient is instructed to perform home modeling and penis stretching.

Main Outcome Measures

The measurements collected were from girth, length of the penis and length of the plaque. Side and degree of curvature. Ultrasound evaluation of the plaque characteristics and assessing the interface between the tunica albuginea and Buck's fascia. Furthermore, questionnaires were collected: International Index of Erectile Function (IIEF) and 15-question and Peyronie's Disease Questionnaire (PDQ). All these parameters were evaluated before and after treatment.

Results

An improvement in curvature was obtained in 76.9% of patients, reaching an improvement in the angle of curvature after the treatment cycles by an average of 19 ° (range 0-35 °) from the beginning. There are also improvements in the results of the IIEF and PDQ questionnaires. Length, penis girth, and plate length measurements hardly changed after treatment. Reported adverse effects are mild and limited to the penis.

Conclusions

We demonstrate the safety and efficacy of CCH in the treatment of PD using a more intense protocol than the previous ones. In addition, reducing the overall duration of allows for greater adherence and compliance of patients. Melgarejo-Segura MT, Funes-Padilla C, Morales-Martínez A, et al. Safety and Efficacy Study of Collagenase Clostridium Histolyticum Applied With an Intensive Protocol in the Treatment of Peyronie's Disease. Sex Med 2021;9:100375.

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

BACKGROUND

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

AIM

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

METHODS

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

OUTCOMES

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

RESULTS

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

CLINICAL IMPLICATIONS

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

STRENGTHS AND LIMITATIONS

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

CONCLUSIONS

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

Treatment Patterns and Healthcare Outcomes with Collagenase Clostridium Histolyticum vs Surgery in Peyronie's Disease: A Retrospective Claims Database Analysis

Introduction

Treatments for Peyronie's disease (PD) include surgical management and collagenase clostridium histolyticum (CCH).

Aims

To evaluate PD treatment trends after CCH approval and compare clinical outcomes in CCH- and surgery-treated cohorts.

Methods

Patients newly diagnosed with PD between January 2011 and December 2017 were identified in a U.S. claims database. Cohorts initiating treatment with CCH or surgery between January 2014 and June 2017 were included. Patients were continuously enrolled ≥6 months before and ≥12 months after index date. Post-treatment penile complications and analgesic use were compared 1 year after procedure in propensity score-matched cohorts.

Main outcome measures

The main outcome measures of this study were treatment patterns, penile complications, and analgesic use.

Results

In the newly diagnosed PD cohort, 1,609 patients received CCH and 1,555 patients had surgery. Overall CCH or surgery treatment rate/year increased from 9.8% in 2014 to 15.5% in 2017, with <1% receiving verapamil or interferon. Initial treatment ratios of CCH to surgery increased from approximately 1:1 (2014) to 2:1 (2017). In the unmatched CCH (n = 1,227) and surgery (n = 620) cohorts, more (P < .05) surgery-treated patients received analgesics (particularly opioids), oral PD therapies, vacuum erection devices, and phosphodiesterase-5 inhibitors before the index date. After propensity score matching (n = 620/cohort), newly occurring postprocedural complications during the follow-up period were higher in the surgery cohort (25.3% vs 18.4%, P = .003). The surgery cohort had significantly (P < .05) higher rates of erectile dysfunction (65.0% vs 44.8%), penile pain (17.9% vs 8.9%), and penile swelling (8.1% vs 5.2%) and was more likely to be prescribed opioids (93.3% vs 38.9%; P < .0001) or non-steroidal anti-inflammatory drugs (27.0% vs 20.3%; P = .006).

Conclusion

CCH demonstrated fewer complications and less analgesic use than surgery and was used as the initial therapy for PD twice as often as surgery.

L Trost, H Huang, X Han, et al. Treatment Patterns and Healthcare Outcomes with Collagenase Clostridium Histolyticum vs Surgery in Peyronie's Disease: A Retrospective Claims Database Analysis. Sex Med 2021;9:100321.

Vascular Necrosis of the Upper Extremity After Self-Treatment for Peyronie's Disease

Peyronie's disease (PD) is associated with significant psychosocial distress, including anxiety, depression, and negative effects on interpersonal relationships. We report outcomes in a patient who researched an enzymatic supplement intended for oral administration for treatment of PD and subsequently self-injected it intravascularly. The enzyme, a combination of serrapeptase and nattokinase, resulted in vascular necrosis of the upper extremity. Despite attempts to salvage the limb, he ultimately required transhumeral amputation. Although extreme, this case illustrates the potential risks of non–Food and Drug Administration–approved therapies, the significant psychosocial impact that PD can have on patients' emotional well-being, and the extent to which some may go to seek treatment.

Yang D, Savage J, Kohler T, et al. Vascular Necrosis of the Upper Extremity After Self-Treatment for Peyronie's Disease. Sex Med 2021;9:100282.

DIFFUSION OF INJECTED COLLAGENASE CLOSTRIDIUM HISTOLYTICUM FOR DUPUYTREN´S DISEASE: AN IN-VIVO STUDY

INTRODUCTION

While injecting Clostridium Histolyticum as a non-surgical tratment for Dupuytrens disease on the palmar side of the hand the recommended depth of the needle should be &#8220;around 2 to 3 mm in depth&#8221;. The diffusion of CCH inside the soft tissues around the cord might explain the occurrence of common adverse events reported in the literature such as oedema, injection site swelling, blood blisters, skin laceration, and pain in extremity. We hypothesized that the injected Collagenase Clostridium Histolyticum does not only concentrate inside the cord but also dissipates both along the cord and into the adjacent tissues. This study investigated our hypothesis by visual intraoperative findings after injecting Povidone iodine into the cord.

MATERIAL AND METHODS

Povidone iodine  (PI)was injected into the cord on six patients with Dupuytrens contracture before an open surgical operation (partial fasciectomy). We marked three hypothetical Collagenase Clostridium Histolyticum injection points at 2 mm intervals on the skin above the cord around the metacarpo-phalangeal joint and the depth of the injection (distance from the skin surface to the middle of the cord) was measured by ultrasonography. After dispensing 0.25 ml of Povidone iodine into the three points at the measured depths, we performed careful dissection and investigated the extent of diffusion of Povidone iodine visually.

RESULTS

The injection depth averaged 2.6 mm. In all cases, the cord was homogenously stained about 10 mm along its extent centrally to the injected sites and infiltration of Povidone iodine into the subcutaneous structure and fat tissue occurred. Three cases showed diffusion into the neurovascular bundles and two cases showed infiltration underneath the cord structure.

CONCLUSIONS

This study simulated the likely diffusion outcomes of injected Collagenase Clostridium Histolyticum around the cord. This implies that even if Collagenase Clostridium Histolyticum is injected into the centre of the cord, it does not concentrate inside the cord only but also dissipates along the cord and infiltrates into the adjacent tissues with potential secondary damages.

Impact of the Advent of Collagenase Clostridium Histolyticum on the Surgical Management of Peyronie's Disease: A Population-Based Analysis

INTRODUCTION

Penile plication or partial excision with grafting has traditionally been the first-line treatment for stable Peyronie's disease (PD). Numerous injection therapies (ITs) have been introduced over the last few decades. Intralesional collagenase clostridium histolyticum (CCH) was U.S. Food and Drug Administration approved in 2013 for patients with stable disease, curvature ≥30° and ≤90°, and intact erectile function. The impact of the advent of CCH on the surgical management of PD is unknown.

AIM

We studied the effect of IT on the surgical management of PD in a population-based analysis.

METHODS

The Statewide Planning and Research Cooperative System database, which provides statewide level of all-payer data on patients in the outpatient, inpatient, ambulatory, and emergency department setting in New York State was reviewed. Patients undergoing a penile prosthesis for concurrent erectile dysfunction were excluded.

MAIN OUTCOME MEASURE

Descriptive statistics and multivariable logistic regression modeling were used to assess factors influencing choice of injection therapy vs surgical therapy (penile plication or partial excision with grafting).

RESULTS

From 2003-2016, 547 patients with PD presented for management. Median age was 56 years and 57% were white. Over the study period, surgical management was used less often as the primary procedure with a concurrent increase in use of IT (P < .001). On multivariable modeling, patients more likely to receive IT as treatment for penile curvature were younger (odds ratio [OR]: 1.26; P = .002; CI: 1.09-1.46), of higher socioeconomic status (OR: 1.14; P = .037; CI: 1.01-1.29), presented in the post-CCH era (OR: 1.17; P = .018; CI: 1.03-1.33) and presented to a surgeon with a high volume practice (OR: 1.25; P = .007; CI: 1.07-1.48). Patients presenting in the post-CCH era were 17% significantly more likely to receive IT.

CLINICAL IMPLICATIONS

ITs like CCH are increasingly displacing surgical management as the primary treatment option of Peyronie's disease.

STRENGTHS & LIMITATIONS

The Statewide Planning and Research Cooperative System database is particularly useful for this analysis because it is an all-payer database that tracks patients longitudinally across various health care settings-outpatient and inpatient.

LIMITATIONS

It only includes patients in New York State limiting generalizability. The retrospective nature of the analysis makes it subject to the biases inherent in such reports. Specific disease level characteristics (eg, degree of curvature, duration of disease, and associated deformities) were not available.

CONCLUSION

Since the introduction of CCH, there has been a markedly decreasing trend in the utilization of surgery as the primary modality in the management of PD-associated penile curvature. Sukumar S, Pijush DB, Brandes S. Impact of the Advent of Collagenase Clostridium Histolyticum on the Surgical Management of Peyronie's Disease: A Population-Based Analysis. J Sex Med 2020;17:111-116.

Predictive Factors of Patients' and Their Partners' Sexual Function Improvement After Collagenase Clostridium Histolyticum Injection for Peyronie's Disease: Results From a Multi-Center Single-Arm Study

BACKGROUND

Collagenase Clostridium histolyticum (CCH; Xiapex) injections represent the only licensed medical treatment for Peyronie's disease (PD).

AIM

To evaluate the efficacy and safety of CCH injections in men with stable PD, using a modified treatment protocol and to assess partners' bother improvement in a large cohort of White-European sexually active heterosexual men treated in a single tertiary-referral center.

METHODS

All the 135 patients enrolled underwent a thorough assessment, which included history taking, physical examination, and pharmacologically induced artificial erection test (intra-cavernous injection) to assess the degree of penile curvature (PC) at baseline and after the completion of the treatment. Patients with calcified plaque and/or ventral curvature were excluded. All patients underwent a modified treatment protocol, which consisted of 3 intra-lesional injections of 0.9 mg of CCH performed at 4-week intervals at the point of maximum curvature. After each injection, patients were instructed to follow a strict routine involving daily penile stretching in the intervals between injections.

OUTCOMES

International Index of Erectile Function (IIEF)-15, Global Assessment of PD, PD questionnaires (PDQ), and Female Sexual Function Index (FSFI) questionnaire were performed at baseline and at the end of treatment.

RESULTS

Overall, 135 patients completed the study protocol. Before treatment, 18 (13.33%) partners showed a degree of sexual dysfunction. Baseline median IIEF-15, FSFI, and PDQ scores were, respectively, 59.0, 35.0, and 23.0. Overall, both IIEF-total and all domains significantly improved after treatment (all P < .01). A PC mean change of 19.07 (P = .00) was measured. At the univariate linear regression analysis, IIEF-15, IIEF-erectile function, IIEF-sexual desire, and IIEF-intercourse satisfaction were positively associated with FSFI (all P ≤ .03); conversely, PDQ-penile pain, PDQ-symptom bother, and post-treament penile curvature (P ≤ .04) were associated with a decreased FSFI score. Furthermore, median change of PC was significantly associated with median change of FSFI (r = 0.25; 95% CI 0.02-0.11; P = .004). Global satisfaction after treatment was 89.6% (121/135).

CLINICAL TRANSLATION

This modified CCH treatment protocol could improve both patients' and partner's sexual function.

STRENGTH AND LIMITATIONS

This was an open-label, single-arm clinical study, without placebo. where only heterosexual couples in stable relationships were included. Furthermore, no real assessment of female sexual distress was carried out and long-term sexual function in both patients and female partners were not taken into account.

CONCLUSIONS

The modified treatment schedule with CCH injections for stable PD has a positive impact on both patients' and partners' sexual function in heterosexual couples with a stable sexual relationship. Cocci A, Russo GI, Salonia A, et al. Predictive Factors of Patients' and Their Partners' Sexual Function Improvement After Collagenase Clostridium Histolyticum Injection for Peyronie's Disease: Results From a Multi-Center Single-Arm Study. J Sex Med 2018;15:716-721.

Collagenase Clostridium Histolyticum Injection with Precise Needle Length Adjusted by Silicone Tube Interposition for Dupuytren Contracture

We describe our injection method for Collagenase Clostridium Histolyticum using a medical silicone tube after determining the optimal depth by ultrasonography. This procedure adjusts the exposed needle length to the planned injection depth by placing a sterilized silicone tube over the needle. The restricted depth provides not only precise injection into the middle of the cords but also avoids needle tip migration through the cord and into the vital structures, which prevents possible complications. This method is safe and simple.

The use of Collagenase Clostridium Histolyticum in the management of Dupuytren's contracture-outcomes of a pilot study in a District General Hospital setting

INTRODUCTION

Collagenase Clostridium Histolyticum (CCH) is a recognised treatment option for adult patients presenting with Dupuytren's contracture (DC).

PATIENTS AND METHODS

Twenty male patients with established DC were treated using CCH. The average metacarpophalangeal (MCP) joint and proximal interphalangeal joint (PIP) contractures pre-treatment were 52⁰ (range, 0 - 75⁰) and 35⁰ (range, 0 - 84⁰) respectively. The average DASH score pre-treatment was 24.2 points (range, 0 - 68.2 points). Patients were reviewed at lmonth, 3months and at an average of 23 months (17 to 27 months).

RESULTS

MCP joint contractures significantly improved compared to pre-treatment and the improvement was maintained at latest follow up. PIP joint contractures did significantly improve but to a lesser degree and there was no significant improvement compared to pre-treatment beyond 3months. A trend for MCP and PIP joint contracture recurrence was observed at latest follow up but did not reach statistical significance. DASH scores significantly improved from pre-treatment and the improvement was maintained at latest follow up. At 3months, the average patient satisfaction score was 9.5 (range, 6 - 10), which decreased to 8.6 (range, 6 - 10) at latest follow up. We estimated a potential cost saving of approximately £70,000 by treating 20 patients using CCH compared to inpatient operative fasciectomy.

CONCLUSION

CCH is a useful option in the management of DC in appropriately selected patients. Cost-effectiveness in the treatment of DC should be carefully considered.

The History of Collagenase Clostridium Histolyticum

INTRODUCTION

After its U.S. FDA approval in 2013, Collagenase Clostridium histolyticum (CCh) has seen increasing use as a nonoperative treatment for Peyronie's disease (PD). We review the history of CCh and trials that led to its adoption.

AIM

To provide a historical and contemporary context for the evolution of Collagenase Clostridium histolyticum as a treatment modality for Peyronie's disease.

METHODS

A comprehensive search of peer-reviewed literature was performed pertaining to CCh and its biochemical and clinical significance.

MAIN OUTCOME MEASURE

The main outcome studied was the efficacy and safety profile of CCh in PD. CCh use in other diseases processes and its associated outcomes are also described.

RESULTS

CCh injection yields objective improvement in penile curvature across multiple trials in PD patients. Recently, level 1 strength of evidence has emerged supporting its widespread use. As such, CCh stands as the only FDA-approved injectable therapy for PD. Adverse events were namely limited to local reactions. Serious systemic complications and need for intervention were rare.

CONCLUSIONS

CCh is a safe and effective treatment for PD patients with deformities and plaque configuration amenable to injectable therapy. Multiple trials have demonstrated improvements in objective and subjective metrics such as penile curvature and bother scores. However, multiyear follow-up is needed to assess durability and its sustained clinical significance. Currently, refinement in dosing and technique has established a niche for CCh in PD patients who are affected by their symptoms but are not yet committed to surgical intervention. Yang KK and Bennett N. The history of collagenase clostridium histolyticum.

Clinical safety and effectiveness of collagenase clostridium histolyticum injection in patients with Peyronie's disease: a phase 3 open-label study

INTRODUCTION

Collagenase clostridium histolyticum (CCH; Xiaflex, Auxilium Pharmaceuticals, Inc., Chesterbrook, PA, USA) is a Food and Drug Administration-approved, intralesional treatment for Peyronie's disease (PD).

AIM

The aim of this study was to assess the safety and effectiveness of CCH in the treatment of PD.

METHODS

This phase 3, open-label study enrolled subjects who were CCH-naïve, were enrolled in a previous pharmacokinetic study, or had received placebo in an earlier phase 2 CCH study. Each treatment cycle included two intralesional injections of CCH 0.58 mg, approximately 24-72 hours apart, and plaque modeling 24-72 hours after the second injection of each cycle. The treatment cycle was repeated after 6 weeks for ≤4 treatment cycles.

MAIN OUTCOME MEASURES

The co-primary end points were the mean percent change in penile curvature deformity and the mean improvement in PD bother score (range 0-16) from baseline to week 36.

RESULTS

Of the 347 subjects treated with ≥1 injection, 238 had both a penile curvature measurement and a Peyronie's Disease Questionnaire response at baseline and ≥1 subsequent time point. Mean baseline penile curvature deformity was 53.0° and mean PD symptom bother was 7.3. Statistically significant mean improvements from baseline to week 36 were observed in both penile curvature deformity (34.4% [95% confidence interval {CI}, 31.2%, 37.6%]) and PD symptom bother score (3.3 [95% CI, 2.8, 3.7]). Most adverse events (AEs) were mild or moderate in severity and local to the penis. There were three serious treatment-related AEs, two penile hematomas and one corporal rupture; all resolved with treatment.

CONCLUSIONS

Potentially clinically meaningful and statistically significant improvements in penile curvature deformity and PD symptom bother scores were observed with intralesional injection of CCH compared with baseline in men with PD. CCH was generally well tolerated, with AEs primarily transient and local to injection site. In conjunction with previous studies, the results of this open-label study support the use of CCH in the treatment of PD.