Editing Peyronie's Disease (section)

== Management ==

* '''2015 AUA and 2018 CUA Guideline Notes are included here'''

* Only clinicians with expertise in Peyronie’s disease should treat affected patients
* Discuss with the patient a care plan, which is consistent with patient symptom status, current health, and treatment goals.

=== Options ===

# '''Observation'''
# '''Intervention'''
## '''Active phase (1):'''
### '''NSAIDs for pain'''
## '''Stable phase'''
### '''Non-surgical (2)'''
#### '''Penile traction'''
#### '''Intralesional injection'''
### '''Surgical (3)'''
#### '''Plication'''
#### '''Plaque excision +/- grafting'''
#### '''Penile prosthesis''' 

=== Observation ===

* '''Patients without pain or difficulty in accomplishing penetrative sex may only require reassurance'''

=== Intervention ===

==== Non-surgical ====

===== Options (4): =====
# '''<span style="color:#ff0000">Penile traction</span>'''
# '''<span style="color:#ff0000">Oral medication</span>'''
# '''<span style="color:#ff0000">Intralesional injection</span>'''
# '''<span style="color:#ff0000">ESWT</span>'''

===== UrologySchool.com Summary of non-surgical interventions for Peyronie's Disease =====
* '''Treatment depends on whether the patient’s symptoms are active (dynamic) vs. stable'''
*'''<span style="color:#ff0000">AUA:</span>'''
** '''<span style="color:#ff0000">Recommended:</span>'''
*** '''<span style="color:#ff0000">Active phase (1):</span>''' 
***#'''<span style="color:#ff0000">NSAIDs for pain</span>'''
*** '''<span style="color:#ff0000">Stable phase (2):</span>''' 
***#'''<span style="color:#ff0000">Penile traction</span>'''
***#'''<span style="color:#ff0000">Intralesional (collagenase, verapamil, interferon alfa-2b) injection with modelling</span>'''
** '''<span style="color:#ff0000">Conditional (1):</span>''' 
**#'''<span style="color:#ff0000">Extracorporeal shockwave therapy for pain</span>'''
**#* Recommendation is Conditional because the broader PD literature indicates that pain is the PD symptom that is most likely to resolve over time without intervention, the patient burden involved in obtaining ESWT treatment to treat pain may be substantial, and other treatments may be equally effective at alleviating pain. Further, ESWT is associated with frequent adverse events
* '''<span style="color:#ff0000">CUA </span>(mostly similar to AUA, except CUA lists some oral medications that may be considered while these are not supported by AUA):'''
** '''<span style="color:#ff0000">Recommended:</span>'''
*** '''<span style="color:#ff0000">Active phase: NSAIDs for pain</span>'''
*** '''<span style="color:#ff0000">Stable phase: penile traction, intralesional treatment with modelling</span>''' '''(first-line: collagenase; second-line: verapamil or interferon where cost or concern related to adverse events limits use of collagenase; AUA does not use similar hierarchy of preferred treatments)'''
** '''<span style="color:#ff0000">May be considered:</span>'''
*** '''<span style="color:#ff0000">Oral medication (alone or as a part of multimodal care) (different than AUA):</span>'''
**** '''<span style="color:#0000ff">Can Consider Peyronie's Pills (4)</span>'''
***# '''<span style="color:#0000ff">C</span><span style="color:#ff0000">olchicine</span>'''
***# '''<span style="color:#0000ff">C</span><span style="color:#ff0000">o-enzyme Q10</span>'''
***# '''<span style="color:#0000ff">P</span><span style="color:#ff0000">otassium paraaminobenzoate</span>'''
***# '''<span style="color:#0000ff">P</span><span style="color:#ff0000">entoxifylline</span>'''
*** '''<span style="color:#ff0000">Extracorporeal shockwave therapy for pain</span>'''

===== Penile traction =====
* '''<span style="color:#ff0000">First-line non-invasive, non-surgical treatment modality</span>'''
* No RCT to date
* '''Associated with (4):'''
*# '''Reduced curvature'''
*# '''Increased stretched penile length'''
*# '''Increased erect girth'''
*# '''Correction of hinge effect'''
** Benefit maintained at 6 months of completion of therapy
* '''Critical that patient wears device for ≥3 hours per day to get satisfactory results'''
* Insert figure

===== Oral medication =====
* '''<span style="color:#ff0000">Oral non-steroidal anti-inflammatory medications can be used for pain in the active phase</span>'''
* '''Tried but not useful/not much evidence:''' '''colchicine, co-enzyme Q10, potassium aminobenzoate''' (Potaba, member of the vitamin B complex), '''pentoxifylline''' (increases nitric oxide; RCT trial retracted 6 years later due to inappropriate statistical analysis), '''carnitine, omege-3 fatty acids, procarbazine, tamoxifen, vitamin E, vitamin E with L-carnitine'''
* '''Low-dose daily tadalafil is a safe and effective treatment option in septal scar remodeling''', but limited evidence

===== Intralesional injection =====
# '''<span style="color:#ff0000">Clostridial collagenase (Xiaflex) with penile modeling</span>'''
#* Produced by the bacterium C. histolyticum
#* Selectively degrades collagen types I and III in connective tissues
#* '''<span style="color:#ff0000">Associated with:</span>'''
#*# '''<span style="color:#ff0000">Decrease in deviation angle</span>'''
#*# '''<span style="color:#ff0000">Reduction in plaque size</span>'''
#** '''<span style="color:#ff0000">Does NOT treat pain or ED</span>'''
#* '''<span style="color:#ff0000">Appropriate in patients with (2)</span>'''
#*# '''<span style="color:#ff0000">Curvature >30° and <90°</span>'''
#*# '''<span style="color:#ff0000">Intact erectile function (with or without the use of medications)</span>'''
#** '''<span style="color:#ff00ff">IMPRESS I & 2</span>'''
#*** '''832 PD patients with (4):'''
#***# '''Stable disease'''
#***#* Use in active phase is considered off-label
#***# '''Curvature > 30° and < 90°'''
#***# '''Single dorsal or lateral plaque'''
#***# '''No isolated hourglass deformity or calcified plaque'''
#***# '''Normal erectile function'''
#*** Randomized to intralesional collagenase vs. placebo
#*** Results:
#**** In both trials, men in the CCh group were shown to exhibit a 17° improvement in penile curvature compared to 9° in the modelling only, placebo group, '''modest absolute difference 8'''°
#** '''To-date, clinical trials have not evaluated the use of collagenase in patients with (5):'''
#**# '''Hourglass deformity'''
#**# '''Ventral curvature'''
#**# '''Calcified plaque'''
#**# '''Plaque located proximal to the base of the penis'''
#**# '''Curvature < 30° and > 90°'''
#* '''<span style="color:#ff0000">Adverse events (5):'''
#*#'''<span style="color:#ff0000">Corporal rupture'''
#*#*'''Extremely rare; will often necessitate surgical repair'''
#*#'''<span style="color:#ff0000">Penile bruising'''
#*#'''<span style="color:#ff0000">Penile pain'''
#*#'''<span style="color:#ff0000">Penile swelling'''
#*#'''<span style="color:#ff0000">Hematoma'''
#* '''<span style="color:#ff0000">Should be combined with penile modeling</span>''' by the physician and patient
#* Discontinued in Europe and Canada in 2020 due to cost and poor market uptake§
# '''<span style="color:#ff0000">Calcium channel blocker</span>'''
## '''<span style="color:#ff0000">Verapamil</span>'''
##* Affects fibroblast function on several levels, including cell proliferation, ECM protein synthesis and secretion, and collagen degradation
##* Evidence for the use of intralesional verapamil is weak
##* '''Poor candidates include those with:'''
##*# '''Extensive calcification'''
##*# '''Curvature >90°'''
##*# '''Ventral curvature''' (difficult to adequately infiltrate the plaque)
##* '''Predictors of success include:'''
##*# '''Younger age (age < 40)'''
##*# '''Curvature >30°'''
##* '''Adverse Events (4):'''
##**'''Penile hematoma'''
##**'''Pain'''
##**'''Dizziness'''
##**'''Nausea'''
## Nicardipine
##* Demonstrated significant reduction in pain, improvement in IIEF-5 score, and reduction of plaque size when compared to placebo
# '''<span style="color:#ff0000">Interferon alfa-2b</span>'''
#* '''Efficacy'''
#**'''Used to reduce curvature, plaque size, pain, and improve some vascular outcomes'''
#**'''Modest improvement compared to placebo'''
#* '''Indications'''
#**'''Curvature > 30° and without calcified plaque'''
#* '''Adverse Events'''
#**'''Sinusitis'''
#**'''Flu-like symptoms of arthralgia'''
#**'''Fevers'''
#**'''Chills'''
#**'''Local effects including penile hematoma, swelling, and pain'''
#*'''Significant cost and side effects'''
#**Rarely used in Canada
*'''Corticosteroids'''
** '''Not recommended''' for intralesional treatment of Peyronie disease
* '''Hyaluronic acid and botulinum toxin A (onabotulinum toxin A)'''
** '''Too early to make any recommendations''' on the use of these medications until more safety and efficacy data are available
* '''Platelet-derived growth factors (platelet-rich plasma)/'''Priapius ShotTM protocols and stem cell therapy
** Patients should be counselled regarding the '''lack of efficacy data'''.

===== Extracorporeal shockwave therapy =====
* Hypothesized mechanism of action: damage to plaque and increased vascularity
* '''Associated with pain reduction, but pain usually resolves spontaneously with time'''
* '''SHOULD NOT be used for the reduction of penile curvature or plaque size; deviation may worsen with shockwave'''

===== Combination therapy of daily pentoxifylline and L-arginine, biweekly verapamil injections, and daily traction =====

* '''Provides the best opportunity for deformity improvement.'''

===== Not effective =====
* '''Topical agents'''
** No topically applied agent (e.g. verapamil gel) has been shown to be effective in the treatment of PD
* '''Transdermal drug delivery''' with verapamil or dexamethosone using electromotive technology
** Was proposed to be superior to oral or injection therapy because it bypasses hepatic metabolism and minimizes the pain of inject. This approach has limited evidence of benefit
* '''Vacuum therapy'''
** Safe but unlikely to be of benefit due to short-term duration of stretching forces
* '''Radiation'''
** Should be avoided because of potential risk of malignant change and increase in the risk of ED in aging patients

==== Surgical ====

===== Indications =====

* '''Indications for surgical intervention in Peyronie’s disease (4):'''
*# '''<span style="color:#ff0000">Stable disease (defined by AUA as disease that is ≥ 1 year from onset and ≥3-6 months of stable deformity)</span>'''
*#* '''CUA considers stable disease after 6-12 months after disease onset and ≥3-6 months of stable deformity'''
*#* The surgical literature focuses almost entirely on patients with stable disease; outcomes for patients with active disease are not known.
*#* Although pain is associated with acute phase, '''surgery may be considered even in the presence of pain''' if persistent penile pain during erection is related to penile deformity.
*# '''<span style="color:#ff0000">Deformity that compromises sexual intercourse</span>'''
*# '''<span style="color:#ff0000">Failure of non-surgical therapy</span>'''
*#* It is not incorrect to bypass medical management and proceed straight to surgery; however, the patient must clearly be aware and have consented to the potential treatment side-effects of surgery.
*# '''<span style="color:#ff0000">Desire for most rapid and reliable result</span>'''

===== Pre-operative counselling (4): =====

# '''<span style="color:#ff0000">Persistent or recurrent curvature</span>'''
#* '''<span style="color:#ff0000">Goal is to make penis “functionally straight”</span>''' (penetration not compromised, usually corresponding to '''<span style="color:#ff0000">residual curvature < 20º)</span>''' vs. completely straight (comparing to pre-PD anatomy))
# '''<span style="color:#ff0000">Reduction of penile erect length</span>'''
#* Result is more likely shorter with plication than with grafting
# '''<span style="color:#ff0000">Diminished rigidity</span>'''
#* ≥5% in all studies—grafting more than plication
#* ≥30% if suboptimal pre-operative rigidity—dependent on pre-operative erectile quality
# '''<span style="color:#ff0000">Decreased sexual sensation</span>'''
#* '''Typically resolves in 1-6 months'''
#* Rarely compromises orgasm or ejaculation

===== Surgical approach =====

* '''<span style="color:#ff0000">Depends on erectile function and severity of deformity</span>'''
* '''<span style="color:#ff0000">Options (3):</span>'''
*# '''<span style="color:#ff0000">Capable of erection (with or without adjunct therapy (oral medications, vacuum pump therapy, or intracavernosal injection) and lack of deformity precluding intercourse</span>'''
*## '''<span style="color:#ff0000">Plication</span>'''
*## '''<span style="color:#ff0000">Plaque incision, partial excision, or excision, with grafting</span>'''
*# '''<span style="color:#ff0000">Refractory erectile dysfunction or severe deformity</span>'''
*## '''<span style="color:#ff0000">Prosthesis</span>'''
*##* Men who are considering penile straightening procedures without a penile prosthesis should be carefully evaluated for the quality of their pre-operative erections
*##** '''CUA Guidelines recommend pre-operative evaluation with combination of colour duplex ultrasonography with intracavernosal injection (CDU-ICI) to delineate both disease extent and intact erectile function; however, CDU-ICI may not be required in cases where normal rigidity is present and digital photographs at full erection delineate disease extent'''
*##** '''Plication may have less risk of new ED compared with grafting procedures. However, grafting more likely to restore penile length compared to plication.'''
*##* '''Post-operative rehabilitation period (e.g. traction)''' is designed to improve postoperative healing and outcomes by (4):
*##*# Preventing shortening
*##*# Encourage straight wound healing
*##*# Preserve vascular integrity
*##*# Encourage partner participation.

====== Tunical plication (tunical shortening procedures) ======

* '''<span style="color:#ff0000">Aims to shorten the longer (or convex) side of the tunica albuginea to match the length to the shorter side</span>'''
* '''<span style="color:#ff0000">Recommended for (3):</span>'''
*# '''<span style="color:#ff0000">Simple curvature <70°</span>'''
*# '''<span style="color:#ff0000">Minimal/absent hourglass or hinge effects</span>'''
*# '''<span style="color:#ff0000">Adequate penile length;</span>''' those in whom the anticipated loss of length would be < 20% of total erect length
* '''Advantages (4):'''
*# '''Shorter surgical time'''
*# '''Good cosmetic outcomes'''
*# '''Minimal effect on rigidity'''
*# '''Simple and safe surgery'''
*# '''Effective straightening'''
* '''Disadvantages (2):'''
*# '''Penile shortening'''
*#* Predictors of shortening include direction and degree of curvature
*#** Ventral curvature >60° has greatest potential for loss of penile length
*# '''Failure to correct an hourglass or hinge'''
* '''Complications (7):'''
*# '''Persistent pain'''
*# '''Persistence or recurrence of penile curvature''' (>30º, ≈10%)
*# '''Penile hematoma''' (≈5%)
*# '''Urethral injury''' (≈1%)
*# '''Palpable suture knots'''
*# '''Loss of penile length by default, but tend to preserve potency'''
* '''<span style="color:#ff0000">Types of plication surgery (3):</span>'''
** '''<span style="color:#ff0000">Nesbit</span>''': '''excision of an elliptical segment''' of the tunica on the contralateral side of the curvature
** '''<span style="color:#ff0000">Yachia</span>''': full-thickness '''vertical incision''' is made on the vertical shaft tunica, which is '''then closed transversely''' to shorten the ventral aspect and correct the curvature
** '''<span style="color:#ff0000">16-dot</span>'''
** '''Imbrication procedures''' are used to avoid making a full-thickness tunical incision and fold the tunica to correct curvature
** '''No head-to-head studies of the primary types of plication surgery'''
* During a dorsal penile plication, the deep dorsal vein is occasionally ligated, dissected, and excised and the plication sutures are then placed in the venous bed.

====== Plaque incision or partial excision and grafting (tunical lengthening procedures) ======

* '''<span style="color:#ff0000">Aims to lengthen the shorter (or concave) side of the tunica albuginea to match the length of the longer side</span>'''
** '''<span style="color:#ff0000">Grafting follows incision, partial excision, or excision of plaque</span>'''
* '''<span style="color:#ff0000">Recommended for:</span>'''
*# '''<span style="color:#ff0000">More complex curves >70°</span>''' (CUA suggests >60°)
*# '''<span style="color:#ff0000">Large plaques</span>'''
*# '''<span style="color:#ff0000">Hourglass or complex deformities</span>'''
*# '''<span style="color:#ff0000">Concern or functional compromise attributable to further length loss with plication approaches</span>'''
** '''Ventral deformity does not do well with grafting procedures'''
* '''<span style="color:#ff0000">Grafting does not ensure length preservation, but offers the advantage of decreasing risk of irreversible erectile tissue damage'''
** '''Grafting associated with increased risk of reduced rigidity compared to plication'''
* '''Must have strong pre-operative erections for grafting''' (either with plaque incision and grafting (PIG) or partial plaque excision and grafting (PEG)) and no evidence of venous insufficiency on duplex ultrasound
* '''Graft material'''
** '''Two most commonly used grafts are Tutoplast (processed human and bovine pericardium), and porcine small intestinal submucosa grafts'''
** Multiple '''autologous grafts have''' been used historically, including fat, dermis, tunica vaginalis, dura mater, temporalis fascia, saphenous vein, crura or albuginea, and buccal mucosa. These have '''fallen out of favor''' because of a need for extended surgery to harvest the graft as well as a second surgical site, which has its own potential complications of healing, scarring, and possible lymphedema
** '''Synthetic grafts,''' including polyester and polytetrafluoroethylene, '''should not be used''' due to increased risks of infection, secondary graft inflammation causing tissue fibrosis, graft contractures, and possibility of allergic reactions

====== Penile prosthesis for men with Peyronie Disease ======

* '''<span style="color:#ff0000">Gold standard treatment for PD requiring surgery occurring concurrently with refractory ED</span>'''
* '''<span style="color:#ff0000">Indications (2):</span>'''
*# '''<span style="color:#ff0000">Severe deformity refractory to non-surgical management or failed plication/grafting</span>'''
*# '''<span style="color:#ff0000">Profound penile instability (buckling or hinge).</span>'''
* '''<span style="color:#ff0000">If significant (> 30°) deformity persists after insertion of the penile prosthesis, additional straightening maneuvers may be necessary including (2):'''
*#'''<span style="color:#ff0000">Manual modeling of the phallus over the inflated device'''
*#*'''Critical steps of modeling'''
*#**Marking the point of maximum curvature
*#**Applying force apposite the point of maximum curvature for 90 seconds
*#**Completely inflating the IPP before modeling
*#**Cycling the device and repeating as necessary
*#**Assuring no injury to the urethra or corpora
*#***'''Most common adverse event occurring after manual modeling during placement of a penile prosthesis is urethral injury'''
*#'''<span style="color:#ff0000">Incising the tunica albuginea with or without grafting''' 
* '''Inflatable penile prosthesis is the preferred surgical implant'''.
** See [[Penile Prosthesis|Penile Prosthesis Chapter Notes]]
** '''Most common postoperative complaint with prosthesis is length loss'''
** Complications may include prosthesis infection, persistent penile shortening or curvature, diminished sensitivity, and mechanical device failure or difficulties.