Editing Peyronie's Disease (section)

==== 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