CUA: Peyronie's Disease (2018)

Link to Original CUA Guideline

See AUA Guideline Notes on Peyronie's Disease

Background

• Definition of Peyronie disease: an acquired penile disorder characterized by benign fibrotic changes primarily to the tunica albuginea, resulting in a constellation of signs and symptoms occurring alone or in combination, including
  1. Penile pain
  2. Penile deformity (curvature, narrowing, indentation, hinging)
  3. Penile shortening
  4. Erectile dysfunction
  5. Plaque formation

Epidemiology

• Prevalence: 9% of men

Natural History

• Plaque-related pain improves and/or resolves in the majority of patients with time even in the absence of treatment. Conversely, spontaneous resolution or significant improvement of penile deformity is rare
  • The natural history of Peyronie disease is complete pain resolution in ≈90% of men
  • Penile curvature only improves in 12% of men, worsens in 48%, and remains stable in 40%.
• The presence of penile pain, especially with erection, increases the likelihood of a penile septal scar, an atypical form of Peyronie disease, which may be characterized by symptoms including penile shortening, pain, and ED, even in the absence of deformity or palpable disease

Diagnosis and Evaluation

• Mandatory (1): history and physical exam
  • History: Onset, duration, history of traumatic event if applicable, deformity and erectile changes over time, acquired vs. lifelong (to differentiate Peyronie disease vs. congenial penile curvature), and medical history inclusive of family presence of Peyronie disease, Dupuytren’s contracture, and other related conditions that may impact erectile and sexual function. Prior Peyronie disease and ED treatments should be documented.
  • Penile characteristics: Determine the extent of penile deformity, direction of curvature, presence of hourglass deformity, palpable plaque(s), interference with intercourse, penile pain with and without erection, shortening, quality of penile rigidity, and presence of hinging. Penile sensation, ejaculatory function, and length/girth concerns should be documented. Digital home photographic documentation may aid in objectively determining treatment effects, especially when non-surgical options are used.
  • Sexual function: Erectile rigidity, ability to penetrate, ability to complete intercourse, and partner complaints and support should be documented. The use of the International Index of Erectile Function-5 (IIEF-5) or the Disease Questionnaire Peyronie’s (PDQ), which is a newer, 15-item, validated instrument specific to Peyronie disease may be of use. Based on bother/psychologic impact, consideration may be made for referral to a mental health professional with expertise in sexuality.
    • A diagnosis of ED or failed first- and second-line ED treatments warrants ruling out Peyronie disease
  • Physical exam:
    • The penis should be examined on the stretch. Palpation should be performed to identify the location, size, number and tenderness of the plaque. Stretched penile length can be determined, as penile length loss is a primary concern and contributor to distress for Peyronie disease patients; this is measured from the penopubic skin junction to the coronal sulcus or the tip of the penis.
    • Prior to non-invasive or invasive treatments (intralesional injection therapy or surgery) and to monitor treatment effect, it is recommended to examine the erection to determine erect penile length, degree of curvature, hourglass deformities, and rigidity of erection. This can be done with digital photographs or examination after penile injection of vasoactive agents (AUA prefers this); penile injection remains the gold standard, especially in patients reporting complex deformity (hourglass or bidirectional curvature) or ED
    • An accurate appraisal of the deformity includes identifying the type(s), magnitude or severity, and evaluating penile stability/buckling. The most reliable means of assessing deformity is the use of intracavernosal injections, with or without colour duplex ultrasonography.
• Optional/not recommended:
  • Imaging:
    • Colour duplex ultrasonography may be offered, but may not be readily available; combination of ultrasound with intracavernosal injection may also identify arterial insufficiency or veno-occlusive dysfunction, influencing choice of Peyronie disease management
    • MRI is an excellent imaging modality for penile pathology, including Peyronie disease, but its routine use in clinical practice is not supported
    • CT and plain radiography do not have a role
  • Laboratory:
    • Routine laboratory testing is not recommended; however, targeted bloodwork may be obtained in response to specific findings on history or physical examination (for example, signs/symptoms of hypogonadism)

Management of Peyronie’s disease

• Discuss with the patient a care plan, which is consistent with patient symptom status, current health, and treatment goals.
• Non-surgical options (5):
  1. Oral and topical therapies
     • Pain control during the active phase of the disease: NSAIDs (same as AUA)
     • May be considered for clinical use, alone or as a part of multimodal care (oral, intralesional, and traction therapies), but there are clear limitations to the evidence (4): potassium para-aminobenzoate, colchicine, co-enzyme Q10, and/or pentoxifylline
       • AUA guidelines describes these treatments as” promising but for which insufficient evidence currently exists to support even a Conditional Recommendation for their use. In the AUA Panel’s view, the treatments in this category are unproven until a larger and/or more rigorous evidence base is available”
     • Not recommended: Vitamin E, tamoxifen, procarbazine, and vitamin E/L-carnitine
     • The use of PDE-5 inhibitors, specifically tadalafil 5 mg OD to modify Peyronie’s plaque progression appears promising, but to date, data is limited to a single published study.
     • The use of electromotive therapy, iontophoresis, with verapamil or dexamethasone is not recommended
     • Uncertain and only potential efficacy is seen with the use of verapamil gel and its use cannot be supported
  2. Intralesional therapies (3):
     • First-line: Clostridial collagenase
     • Second-line: verapamil or interferon where cost or concern related to adverse events limits use of collagenase
     1. Collagenase (XiaflexTM)
        • IMPRESS I & 2 are RCTs that evaluated collagenase (CCh) with modelling in patients with (4):
          1. Stable disease
             1. Use in active phase is considered off-label
          2. Curvature > 30° and < 90°
          3. No isolated hourglass deformity or calcified plaque
          4. Normal erectile function
          5. 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, absolute difference 8°
        • While uncommon, reported adverse events included:
          1. Significant penile hematomas
          2. Injection site pain
          3. Penile swelling
          4. Corporal rupture, while possible, was extremely rare, but often will necessitate surgical repair
        • Use of this technique in men with hinge defects, ventral curvature, hourglass deformities, curvature < 30° and > 90° has not been evaluated.
     2. Verapamil
        • Common reported adverse events include penile bruising, swelling, and pain at the injection site
     3. Interferon alpha-2b
        • Rarely used in Canada owing to cost and incidence of adverse events
        • Common adverse events include sinusitis, flulike symptoms of arthralgia, fever and chills; and local effects of the injection, such as bruising and swelling. In most cases, symptoms were effectively treated with over the counter non-steroidal anti-inflammatory agents and oral hydration.
        • Can be used in men with curvature > 30° without calcified plaques with modest efficacy
     • 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.
  3. Mechanical therapy – penile traction
     • Recommended as part of Peyronie disease management as it appears to have some activity in correcting penile pain, curvature, and maintenance of penile length
  4. Extracorporeal shockwave lithotripsy
     • Can potentially be used for penile pain improvement
  5. Radiation therapy
     • Use not supported

• Surgical management of Peyronie disease
  • Peyronie disease should be stable when surgical intervention is being considered. General criteria include (3):
    1. A minimum of 6–12 months after disease onset
    2. Plaque stability for 3–6 months
    3. Deformity precluding or making intercourse difficult
    • 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. 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.
  • Pre-operative evaluation
    • Combination of colour duplex ultrasonography with intracavernosal injection (CDU-ICI) is the gold standard and recommended to delineate both disease extent and intact erectile function; CDU-ICI may not be required in cases where normal rigidity is present and digital photographs at full erection delineate disease extent
  • Options (3):
    1. Tunical plication
       • Preferred for men with intact erectile function (with or without pharmacotherapy) and
         1. Adequate penile length
         2. Curvature that is reasonably correctable with this approach
         3. Minimal/absent hourglass deformity causing hinging
       • No head-to-head studies of the primary types of plication surgery, named Nesbit, Yachia, 16-dot or pure plications, and tunica albuginea plication (TAP) procedures.
       • It may be reasonable to consider adding traction to these patients’ postoperative routines
       • Complications may include (7):
         1. Persistent pain
         2. Persistence or recurrence of penile curvature (>30º, ≈10%)
         3. Penile hematoma (≈5%)
         4. Urethral injury (≈1%)
         5. Palpable suture knots
         6. Sensation loss
         7. Loss of penile length by default, but tend to preserve potency
    2. Plaque incision/excision with grafting
       • Preferred for men with intact erectile function with
         1. Severe curvature, simple curvature >60º indentation,
         2. Large plaques
         3. Hourglass or complex deformities
         4. Concern or functional compromise attributable to further length loss with plication approaches
       • Grafting follows incision, partial excision, or excision of plaque
       • Grafting does not ensure length preservation, but offers the advantage of decreasing risk of irreversible erectile tissue damage; increased risk of decreased rigidity with grafting compared to plication
       • 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
    3. Penile prosthesis
       • Gold standard treatment for PD requiring surgery occurring concurrently with refractory ED, and is appropriate for severe deformity refractory to non-surgical management or failed plication/grafting, and with profound penile instability (buckling or hinge).
       • Complications may include prosthesis infection, persistent penile shortening or curvature, diminished sensitivity, and mechanical device failure or difficulties.
  • Patient counselling (3):
    1. Patients must be made aware of the concept of “functionally straight” (penetration not compromised, usually corresponding to residual curvature < 20º) vs. completely straight (comparing to pre-PD anatomy)
    2. Loss of length with tunical shortening approaches
    3. Decreased sexual function (i.e., ED, decreased penile sensation) with any surgical procedure

Congenital Penile Curvature

• See section in Pediatrics External Genitalia Anomalies Chapter Notes
• Results from disproportionate development of the tunica albuginea of the corporal bodies; not associated with urethral malformation
• Patients typically present younger, often in their late teens and 20s
• Unlike Peyronie disease, congenital penile curvatures are most commonly ventral curvatures, with preserved penile length and typically normal erectile function and rigidity
• Treatment is surgical and is offered to patients whose congenital penile curvatures significantly interferes with satisfactory sexual relations of the patient or partner. Plication is used almost exclusively

See Figure 1 from CUA Guidelines

Questions

• See Questions in Peyronie's Disease Chapter Notes