Intralesional Injection Therapy and Atypical Peyronie's Disease: A Systematic Review

Injection therapy in the acute phase of Peyronie's disease: a systematic review of current evidence

BACKGROUND

Injection therapy has emerged as a possible treatment for the acute phase of Peyronie's disease (PD).

AIM

To systematically review the current evidence on the efficacy and safety of injection therapy for patients in the acute phase of PD.

METHODS

A comprehensive bibliographic search on the MEDLINE, Scopus, and Web of Science Core Collection databases was conducted in June 2024. Articles were selected if they included patients with PD in acute phase (P) undergoing injection therapy (I) with or without comparison with other treatments (C), evaluating its efficacy or safety (O). Prospective and retrospective original studies were included (S). Articles were assessed for risk of bias using Cochrane risk-of-bias tool for randomized trials version 2, risk of bias in non-randomized studies-of interventions, and Joanna Briggs Institute critical appraisal tool. Data were synthesized narratively.

OUTCOMES

Primary outcomes were penile curvature, penile pain, and adverse events.

RESULTS

A total of 20 studies (1291 patients) were included, with 4 (20%) being randomized controlled trials. The mean/median duration of PD symptoms ranged from 2.0 to 18.6 months across the papers. The injectable agents tested included calcium channel blockers, hyaluronic acid, Collagenase Clostridium histolyticum, interferon, and corticosteroids. In most studies, improvements in penile curvature and pain were observed, with variable magnitude and in a varying percentage of patients. Adverse events were mostly mild and localized, including bruising, swelling, and ecchymosis. No severe complications were reported in any of the studies.

CLINICAL IMPLICATIONS

Limited evidence support the feasibility of injection therapy for the acute phase of PD.

STRENGTHS AND LIMITATIONS

The first systematic review on injection therapy for acute PD. Low-to-intermediate quality and heterogeneous methodology of primary studies, impossibility of reliable quantitative data synthesis.

CONCLUSION

Injection therapy for the acute phase of PD demonstrates variable efficacy depending on the agent used and a relatively favorable safety profile; however, the overall quality of evidence remains low and is characterized by significant methodological limitations.

Surgical management of complex curvature in Peyronie's disease

PURPOSE

About 10% of Peyronie's patients are complex cases with severe curvature (>60 degrees), ventral plaque, multiplanar curvature, hour-glass/hinge deformity, notching deformity, and ossified plaque. In patients with complex Peyronie's disease (PD), different techniques (shortening procedures, lengthening procedures, and penile prosthesis implantation (IPP)) may be necessary to achieve successful result. This review aims to analyze the various surgical techniques employed in the management of Peyronie's disease, with a specific focus on patients with complex deformity.

METHODS

Articles focusing on the surgical management of complex curvature in Peyronie's disease were searched in MEDLINE and PubMed published between 1990 and 2023.

RESULTS

Shortening procedures are linked to penile shortening and are not recommended for complex cases such as notching, hour-glass deformity, or ossified plaque. Lengthening procedures are suitable for addressing complex curvatures without erectile dysfunction (ED) and are a more appropriate method for multiplanar curvatures. Penile prosthesis implantation (IPP), with or without additional procedures, is the gold standard for patients with ED and Peyronie's disease. IPP should also be the preferred option for cases of penile instability (hinge deformity) and has shown high satisfaction rates in all complex cases.

CONCLUSION

While surgical interventions for complex curvature in Peyronie's disease carry inherent risks, careful patient selection, meticulous surgical techniques, and post-operative care can help minimize complications and maximize positive outcome.

[Current treatment concepts for Peyronie's disease]

Plastic induration of the penis (PIP, Peyronie's disease) is an acquired and chronic disease of the penis, which is characterized by penile pain, distortion and deformation of the penis as well as the resulting impairments in sexual activity of the patient. The most probable causes are microtrauma and macrotrauma within the tunica albuginea of the corpora cavernosa, which due to an abnormal wound healing subsequently leads to the formation of fibrosis in this region. Various predisposing factors and also a genetic predisposition are discussed. The PIP occurs most frequently in the fifth to sixth decades of life. The prevalence is 0.3-20% depending on the investigated collective and the risk factors present. The PIP is subdivided into an acute inflammatory phase and a chronic postinflammatory phase. Various conservative and surgical treatment options include oral medication, penile traction therapy, intralesional injections and surgical procedures.

Peyronie's Disease: A Brief Overview

Peyronie's disease is an acquired connective tissue disease of the tunica albuginea of the penis which usually presents with penile curvature/deformity and a palpable penile plaque. It is more common in Caucasian men over the fifth decade of life, but it is an under-reported disease. Conservative and non-surgical options are supported by limited evidence except for intralesional injection of collagenase clostridium histolyticum and have limited success. The improved outcome of surgical treatment is accompanied by the risk of erectile dysfunction. This is a brief overview of Peyronie's disease, its impact on the patient, and the available treatment options.

Pharmacotherapy in Peyronie's disease: a state-of-the-art review on established contemporary and emerging drugs

INTRODUCTION

Current clinical guidelines on Peyronie's disease (PD) advocate non-surgical treatment options as the first-line therapy despite inconsistent clinical outcomes when compared to definitive penile reconstructive surgery.

AREAS COVERED

This article examines the current understanding of established contemporary and emerging pharmacotherapies for PD. Emphasis has been placed on published clinical studies on drugs in the last 10 years.

EXPERT OPINION

Published studies have shown that combination therapy is likely more effective than monotherapy. Combined treatment modalities involving various oral and/or intralesional pharmacotherapies together with mechanical devices or clinical psychosexual therapy may provide additional or synergistic benefits for PD patients. A multidisciplinary approach coupled with more novel targets for pharmacological intervention could deliver a more effective treatment paradigm to prevent or at least delay the need for definitive penile reconstructive surgery. Drugs targeting the inhibition of TGF-β1 pathway and myofibroblast transformation are of great interest and studies into next-generation genetic sequencing and transcriptional biomarker regulatory pathways in PD will provide useful insights into the pathophysiology of PD, and assist the development of future regenerative technology including cellular-based therapies to target various anti-fibrotic molecular mechanisms and the potential to be integrated into existing treatment armamentarium for PD.