Peyronie's Disease (2015)

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):
1. Acquired penile abnormality
2. Characterized by fibrosis of the tunica albuginea
3. Which MAY be accompanied by (4) Peyronie’s Disease Erectile Dysfunction:
  1. Pain
  2. Deformity
  3. Erectile dysfunction
  4. Distress
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
Natural history: PD is characterized by symptoms with a variable course, some of which may improve or resolve without treatment in some patients.
- Pain will usually resolve over time without intervention; curvature, is much less likely to improve and may require treatment if it compromises sexual function and/or is the source of patient or partner distress
PD can have a profound negative impact on men’s QoL. Many men with PD experience emotional distress, depressive symptoms, and relationship difficulties.

Symptoms:
- The plaque may restrict tunica lengthening on the effected side during erection, which can lead to penile curvature, penile deformity, penile discomfort, penile pain, erectile dysfunction
- “The recent onset of penile curvature and varying degrees of penile pain, without a palpable penile abnormality, in the non-erect state, may be considered diagnostic”
Active vs. Stable Disease
- Active disease:
  - Characterized by dynamic and changing symptoms
  - Defining symptom: penile and/or glanular pain or discomfort with or without erection
- Stable disease:
  - Symptoms have been clinically quiescent or unchanged for ≥3 months
  - Pain with or without erection may be present but is less common
  - Additional symptoms include difficulty in maintaining erectile function and inability to sustain intercourse
Differential diagnosis (4):
1. Congenital penile curvature
2. Thrombosed or torn dorsal penile vein
3. Penile fracture
4. Penile cancer (rarely)

Mandatory (2):
1. History (to assess penile deformity, interference with intercourse, penile pain, and/or distress)
2. Physical exam of the genitalia (to assess for palpable abnormalities of the penis)
- - Measurement of stretched penile length from the penopubic skin junction to the coronal sulcus or the tip is recommended to establish baseline penile length prior to any intervention.
  - Plaque(s) can be palpated or documented on ultrasound.
    - The most common plaque location is on the dorsal mid-shaft
Recommended (1):
- In-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound should be performed prior to invasive intervention (e.g., intralesional treatments, penile prosthesis placement, or surgery)
  - The ICI test enables assessment of penile deformity, plaque(s), and pain in the erect state.
  - When the ICI test is combined with duplex ultrasound, additional measurements of plaque size and/or density can be made, calcified and non-calcified plaques can be differentiated, and information on the vascular integrity of the penis can be obtained.
  - 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.

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

Intralesional options (3):
1. Intralesional collagenase clostridium histolyticum and modeling by the physician and patient
  - Used to reduce penile curvature; does NOT treat pain or ED
  - Appropriate in patients with curvature >30° and <90° and intact erectile function (with or without the use of medications)
    - 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
    - The magnitude of treatment effect beyond placebo is modest
  - Potential adverse effects: penile bruising, pain, swelling, and corporal rupture
2. Intralesional Interferon α-2b
  - Used to reduce curvature, plaque size, pain, and improve some vascular outcomes
  - Appropriate in patients with curvature > 30° and without calcified plaque
    - The magnitude of treatment effect beyond placebo is modest
  - Potential adverse effects: sinusitis, flu-like symptoms, and minor penile swelling
3. Intralesional verapamil
  1. Evidence for the use of intralesional verapamil is weak
  2. Potential adverse effects: penile bruising, pain, dizziness, and nausea

Extracorporeal shock wave therapy (ESWT)
- Can be used for penile pain
  - 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

Oral therapies (vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or a combination of vitamin E with L-carnitine)
Electromotive therapy with verapamil
Radiotherapy

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
- The surgical literature focuses almost entirely on patients with stable disease; outcomes for patients with active disease are not known.
Options:
- 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):
  1. Tunical plication surgery to improve penile curvature
  2. 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

See CUA Guideline Notes on Peyronie's Disease