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Peyronie's Disease (2015): Difference between revisions

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Created page with "Link to Original AUA Guideline See 2018 CUA Guideline Notes on Peyronie's Disease ===== *****All of the content below is included in the more comprehensive Peyronie's Disease Chapter Notes***** ===== == Background == * '''Definition of Peyronie’s disease (PD):''' *# '''Acquired penile abnormality''' *# '''Characterized by fibrosis of the tunica albuginea''' *# '''Which MAY be accompanied by (4) Peyronie’s Disease Erectile Dysfunction:''' *** '''Pain''' *** '''Def..."
 
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Link to Original AUA Guideline
Link to [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027990/ Original AUA Guideline]


See 2018 CUA Guideline Notes on Peyronie's Disease
See 2018 CUA Guideline Notes on Peyronie's Disease


===== *****All of the content below is included in the more comprehensive Peyronie's Disease Chapter Notes***** =====
'''*****All of the content below is included in the more comprehensive [[Peyronie's Disease|Peyronie's Disease Chapter Notes]]*****'''


== Background ==
== Background ==
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*# '''Characterized by fibrosis of the tunica albuginea'''
*# '''Characterized by fibrosis of the tunica albuginea'''
*# '''Which MAY be accompanied by (4) Peyronie’s Disease Erectile Dysfunction:'''
*# '''Which MAY be accompanied by (4) Peyronie’s Disease Erectile Dysfunction:'''
*** '''Pain'''
*##'''Pain'''
*** '''Deformity'''
*##'''Deformity'''
*** '''Erectile dysfunction'''
*##'''Erectile dysfunction'''
*** '''Distress'''
*##'''Distress'''
* '''Pathophysiology: inflammatory disorder of the tunica albuginea'''
* '''Pathophysiology: inflammatory disorder of the tunica albuginea'''
** '''Microvascular trauma to the penile shaft associated with penile buckling in the erect or semi-erect state secondary to sexual activity is thought to be the most common inciting event,''' though most men cannot recall a specific event
** '''Microvascular trauma to the penile shaft associated with penile buckling in the erect or semi-erect state secondary to sexual activity is thought to be the most common inciting event,''' though most men cannot recall a specific event
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* PD can have a profound negative impact on men’s QoL. Many men with PD experience emotional distress, depressive symptoms, and relationship difficulties.
* PD can have a profound negative impact on men’s QoL. Many men with PD experience emotional distress, depressive symptoms, and relationship difficulties.


== Patient presentation of Peyronie’s disease ==
== Clinical Presentation ==


* '''Symptoms''':
* '''Symptoms''':
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*# '''Penile cancer (rarely)'''
*# '''Penile cancer (rarely)'''


== Diagnosis and Evaluation of Peyronie’s disease ==
== Diagnosis and Evaluation ==


* '''Mandatory (2):'''
* '''Mandatory (2):'''
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*** '''Home photography of the erect penis with the use of a protractor during an erection in the office may be sufficient to document deformity from some cases.'''
*** '''Home photography of the erect penis with the use of a protractor during an erection in the office may be sufficient to document deformity from some cases.'''


== Treatment of Peyronie’s disease ==
== Management ==


* Only clinicians with expertise in Peyronie’s disease should treat affected patients
* Only clinicians with expertise in Peyronie’s disease should treat affected patients
* '''Treatment depends on whether the patient’s symptoms are active (dynamic) vs. stable'''
* '''Treatment depends on whether the patient’s symptoms are active (dynamic) vs. stable'''
* '''Active phase:'''
 
** '''Oral non-steroidal anti-inflammatory medications can be used for pain'''
=== Active phase ===
* '''Stable phase:'''
* '''Oral non-steroidal anti-inflammatory medications can be used for pain'''
** '''Recommended:'''
 
*** '''Intralesional options (3):'''
=== Stable phase ===
***# '''Intralesional collagenase clostridium histolyticum and modeling''' by the physician and patient
 
***#* '''Used to reduce penile curvature; does NOT treat pain or ED'''
==== Recommended ====
***#* '''Appropriate in patients with curvature >30° and <90° and intact erectile function (with or without the use of medications)'''
* '''Intralesional options (3):'''
***#** '''To-date, clinical trials have not evaluated the use of collagenase in patients with hourglass deformity, ventral curvature, calcified plaque, or plaque located proximal to the base of the penis'''
*# '''Intralesional collagenase clostridium histolyticum and modeling''' by the physician and patient
***#** '''The magnitude of treatment effect beyond placebo is modest'''
*#* '''Used to reduce penile curvature; does NOT treat pain or ED'''
***#* '''Potential adverse effects: penile bruising, pain, swelling, and corporal rupture'''
*#* '''Appropriate in patients with curvature >30° and <90° and intact erectile function (with or without the use of medications)'''
***# '''Intralesional Interferon α-2b'''
*#** '''To-date, clinical trials have not evaluated the use of collagenase in patients with hourglass deformity, ventral curvature, calcified plaque, or plaque located proximal to the base of the penis'''
***#* '''Used to reduce curvature, plaque size, pain, and improve some vascular outcomes'''
*#** '''The magnitude of treatment effect beyond placebo is modest'''
***#* '''Appropriate in patients with curvature > 30° and without calcified plaque'''
*#* '''Potential adverse effects: penile bruising, pain, swelling, and corporal rupture'''
***#** '''The magnitude of treatment effect beyond placebo is modest'''
*# '''Intralesional Interferon α-2b'''
***#* '''Potential adverse effects: sinusitis, flu-like symptoms, and minor penile swelling'''
*#* '''Used to reduce curvature, plaque size, pain, and improve some vascular outcomes'''
***# '''Intralesional verapamil'''
*#* '''Appropriate in patients with curvature > 30° and without calcified plaque'''
****** Evidence for the use of intralesional verapamil is weak
*#** '''The magnitude of treatment effect beyond placebo is modest'''
***** '''Potential adverse effects: penile bruising, pain, dizziness, and nausea'''
*#* '''Potential adverse effects: sinusitis, flu-like symptoms, and minor penile swelling'''
** '''Conditional:'''
*# '''Intralesional verapamil'''
*** '''Extracorporeal shock wave therapy (ESWT)'''
*#* Evidence for the use of intralesional verapamil is weak
**** '''Can be used for penile pain'''
*#* '''Potential adverse effects: penile bruising, pain, dizziness, and nausea'''
***** 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.
 
**** '''SHOULD NOT be used for the reduction of penile curvature or plaque size'''
==== Conditional ====
** '''Not recommended (3):'''
* '''Extracorporeal shock wave therapy (ESWT)'''
**# '''Oral therapies (vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or a combination of vitamin E with L-carnitine)'''
** '''Can be used for penile pain'''
**# '''Electromotive therapy with verapamil'''
*** 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.
**# '''Radiotherapy'''
** '''SHOULD NOT be used for the reduction of penile curvature or plaque size'''
** '''Surgical reconstruction'''
 
*** '''Patients who are considering surgical reconstruction should have chronic, stable disease, i.e. the presence of Peyronie’s disease symptoms ≥12 months and stable curvature for 3-6 months'''
==== Not recommended (3): ====
**** The surgical literature focuses almost entirely on patients with stable disease; outcomes for patients with active disease are not known.
# '''Oral therapies (vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or a combination of vitamin E with L-carnitine)'''
*** '''Options:'''
# '''Electromotive therapy with verapamil'''
**** '''Treatment is based on baseline erectile function'''; because tunical plication or plaque incision/excision with or without grafting are not treatments for ED and because the consequences of these procedures with regard to erectile function remain unclear, the most appropriate candidates for surgery are patients with intact erectile function or with ED responsive to oral medications or vacuum pump therapy
# '''Radiotherapy'''
**** '''For patients with capable erectile function''' '''(with or without adjunct therapy''' (oral medications, vacuum pump therapy, or intracavernosal injections)) '''and lack of deformity adequate for intercourse, options include (2):'''
 
****# '''Tunical plication surgery to improve penile curvature'''
==== Surgical reconstruction ====
****# '''Plaque incision or excision and/or grafting to improve penile curvature'''
* '''Patients who are considering surgical reconstruction should have chronic, stable disease, i.e. the presence of Peyronie’s disease symptoms ≥12 months and stable curvature for 3-6 months'''
**** '''For patients with erectile dysfunction (ED) and/or penile deformity sufficient to impair coitus despite adjunct therapy'''
** The surgical literature focuses almost entirely on patients with stable disease; outcomes for patients with active disease are not known.
***** '''Inflatable penile prosthesis'''
* '''Options:'''
****** Can perform adjunctive intra-operative procedures, such as modeling, plication or incision/grafting, when significant penile deformity persists after insertion of the penile prosthesis
** '''Treatment is based on baseline erectile function'''; because tunical plication or plaque incision/excision with or without grafting are not treatments for ED and because the consequences of these procedures with regard to erectile function remain unclear, the most appropriate candidates for surgery are patients with intact erectile function or with ED responsive to oral medications or vacuum pump therapy
** '''For patients with capable erectile function''' '''(with or without adjunct therapy''' (oral medications, vacuum pump therapy, or intracavernosal injections)) '''and lack of deformity adequate for intercourse, options include (2):'''
**# '''Tunical plication surgery to improve penile curvature'''
**# '''Plaque incision or excision and/or grafting to improve penile curvature'''
** '''For patients with erectile dysfunction (ED) and/or penile deformity sufficient to impair coitus despite adjunct therapy'''
*** '''Inflatable penile prosthesis'''
**** Can perform adjunctive intra-operative procedures, such as modeling, plication or incision/grafting, when significant penile deformity persists after insertion of the penile prosthesis


== Questions ==
== Questions ==
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