Extracorporeal shock wave therapy in the management of Peyronie's disease: initial experience

Updated recommendations on the therapeutic role of extracorporeal shock wave therapy for peyronie's disease: systematic review and meta-analysis

BACKGROUND

The therapeutic role of extracorporeal shockwave therapy (ESWT) for Peyronie's disease (PD) has been controversial in a long term. We aimed to further evaluate the therapeutic effect of ESWT for PD on the basis of available high-quality studies.

METHODS

The PubMed, CENTRAL and Embase databases were searched for articles published from January 1st, 2000 to December 31, 2022. Only randomized controlled trials (RCTs) using ESWT to treat PD were included. Meta-analysis and forest plots were carried out using Review Manager 5.4.1 software, and outcomes were reviewed by 2 authors independently. Using the Risk of Bias assessment form (ROB-2) by Cochrane Collaboration for quality assessment. PRISMA 2020 guidelines were used in this article to achieve the quantitative and qualitative synthesis of data.

RESULTS

A total of four RCTs were included. 151 patients in the ESWT group and 150 patients in the control group. The meta-analysis results showed that ESWT could significantly reduce plaque size (OR 2.59, 95%CI 1.15 to 5.85, P = 0.02) and relieve pain (MD -1.55, 95%CI -2.46 to -0.64, P = 0.0008); but it has no significant effect on reducing the penile curvature (OR 1.93, 95%CI 0.87-4.26, P = 0.11) and improving sexual function (MD 2.6, 95%CI -1.63 to 6.83, P = 0.23), there is also no significant difference in complication rates between groups (OR 2.94, 95%CI 0.66 to 13.03, P = 0.16). The risk of bias of results is low. The limitations of this study are that the number of included studies is too small, some experimental outcomes are missing, and the expression of outcomes is not unified.

CONCLUSIONS

For PD, ESWT can be considered as a safe short-term treatment, which can reduce plaque size and relieve pain, but cannot improve penile curvature and sexual function. Its long-term efficacy remains to be discussed.

REGISTRATION NUMBER

PROSPERO (ID: CRD42023436744).

A systematic review of non-surgical management in Peyronie's disease

The efficacy of many non-surgical treatments for Peyronie's disease is unclear. This systematic review aims to critically assess the currently available options and provide a recommendation for treatment based on this. A systematic literature search utilising the Medline (Pubmed), Embase, global health and Cochrane library databases was conducted up to May 2021. All randomised controlled trials assessing non-surgical treatment modalities for Peyronie's Disease were included. Individual study risk of bias was evaluated using the Cochrane tool and GRADE was used to assess evidence strength. Outcome measures were the change in penile curvature (degrees), plaque size (volume or size), International Index of Erectile Function score, pain scores and change in penile length. Prospero registration number: CRD42017064618. Amongst the 5549 articles identified, 41 studies (42 reports) were included. Seven different oral treatment options including vitamin E supplementation showed evidence for improving outcomes such as penile curvature and plaque size. Of the intralesional treatments, Collagenase Clostridium Histolyticum showed evidence for improving penile curvature (Range: 16.3-17 degrees, moderate level certainty of evidence). Intralesional Interferon demonstrated some improvement in curvature (Range: 12-13.5 degrees), plaque size (Range: 1.67-2.2 cm2) and pain, whilst intralesional calcium channel blockers such as Verapamil showed variable evidence for changes in the plaque size and pain. Extracorporeal Shockwave Therapy consistently demonstrated evidence for improving penile pain in stable disease, and two mechanical traction devices improved curvature. Iontophoresis, topical medications, and combination therapies did not demonstrate any consistent improvements in outcome measures. Intralesional options demonstrate the best potential. Overall, results varied with few high-quality randomised trials present.

Platelet-rich plasma in patients affected with Peyronie's disease

Objectives

The objective of our study is to discover and evaluate the effects of repeated intralesional injections inside the tunica albuginea of platelet-rich plasma (PRP) in the treatment of Peyronie's disease (PD).

Methods

As part of a prospective study over 12 months from February 2020 until February 2021, on Sixty-five patients with Peyronie's disease, and penile curvature between 25 and 45°. Patients were stratified into two groups, the first with a curvature between 25 and 35° and the second between 35 and 45°. Gathered data included patient-demographics, Injection technique, outcomes: both quantitative (curvature assessments) and qualitative (state of erectile function, pain during intercourse), and complications.

Results

Patients in both groups received an average of 6.1 injections of PRP during the study period. Angulation was significantly improved in both groups an average final improvement of 16.88° (SD = 3.35) (p < 0.001) in the first group and 17.27° (SD = 4.22) (p < 0.001) in the second group. Pain during sex decreased from 70.7% to 34.25%, and 55.5% of patients had easier sexual intercourse.

Conclusions

The positive results of our series of treatment for Peyronie's disease by injection of platelet-rich plasma are encouraging both methodologically (simplicity) and clinical (safety and efficacy) as well as patient satisfaction.

Follow-up of clinical and sonographic features after extracorporeal shock wave therapy in painful plantar fibromatosis

Background

Extracorporeal shock wave therapy (ESWT) has been used as a safe alternative treatment for refractory musculoskeletal diseases, such as plantar fasciitis, Achilles tendinopathy and gluteal tendinopathy, and various forms of fibromatosis including palmar or penile fibromatosis. However, there is limited published data for clinical and sonographic features of plantar fibromatosis after ESWT. The purpose of this study was to evaluate the long-term clinical outcome of ESWT in ultrasonography-confirmed plantar fibromatosis and ultrasonographic changes of plantar fibroma after ESWT.

Methods

Medical charts of 26 patients (30 feet) with plantar fibromatosis confirmed by ultrasonography were reviewed. Finally, a total of 10 feet who underwent ESWT for “Poor” or “Fair” grade of Roles-Maudsley Score (RMS) and symptoms persisted for >6 months were included in this study. Short-term follow-up was conducted one week after ESWT and long-term follow-up time averaged 34.0 months. The Numerical Rating Scale (NRS) and RMS were collected for the evaluation of clinical features. Follow-up ultrasonography was conducted at long-term follow-up and changes of plantar fibroma was assessed. A greater than 50% reduction in the NRS and achievement of a “good” or “excellent” grade in the RMS were regarded as treatment success. Additionally, medical charts of 144 patients (168 feet) with plantar fasciitis confirmed by ultrasonography were reviewed and subsequently, 42 feet who underwent ESWT with the same protocol were included for the comparison of clinical features.

Results

In plantar fibromatosis, baseline NRS (6.2 ± 1.3) and RMS (3.5 ± 0.5) were significantly improved at short-term follow-up (NRS, 1.8 ± 1.0; RMS, 2.0 ± 0.8, P < .001, respectively) and long-term follow-up (NRS, 0.6 ± 1.1; RMS, 1.4 ± 0.8, P < .001, respectively). Treatment success was recorded in seven feet (70.0%) at short-term follow-up and 8 feet (80%) at long-term follow-up, which is comparable to that of the plantar fasciitis group (28 feet, 66.7%; 35 feet, 83.3%, respectively). In long-term follow-up ultrasonography, mean fibroma thickness was reduced from 4.4±1.0 to 2.6±0.8 mm (P = .003); however, length and width were not significantly changed. There were no serious adverse effects.

Conclusion

While these are preliminary findings, and must be confirmed in a randomized placebo control study, ESWT can have a beneficial long-term effect on pain relief and functional outcomes in painful plantar fibromatosis. However, ESWT is unlikely to affect the ultrasonographic morphology of plantar fibroma, with the exception of reducing the thickness.

Level of evidence

Level III, retrospective cohort study.

Non-conventional therapies for Peyronie's disease: what is the evidence for efficacy?

Background

In recent years, there has been a surge in non-conventional therapies for Peyronie’s disease (PD). With increasing interest in these novel therapies, we conducted a narrative review to explore the efficacy and safety of these treatments to provide clarity for patients and providers.

Methods

A literature search was conducted to find studies describing non-conventional treatments of PD. These treatments were defined as those within the standard of care, including intralesional therapies and surgical options.

Results

A total of 14 studies were found. Non-conventional therapies included platelet-rich plasma (PRP), hyaluronic acid (HA), combination therapy of PRP and HA, extracorporeal shockwave therapy (ESWT), stem cell therapy (SCT), mycophenolate mofetil (MMF), and H-100. Most studies were limited to animal models and reported modest improvements in angulation and erectile function. Complication rates and cost of each treatment were infrequently reported.

Conclusions

There is limited evidence supporting non-conventional therapies for PD. As such, they are currently not recommended in clinical guidelines.

Plantar Fibromatosis: Pathophysiology, Surgical and Nonsurgical Therapies: An Evidence-Based Review

Plantar fibromatosis (morbus Ledderhose), an extra-abdominal desmoid tumor of the plantar foot, is a rare benign hyperproliferative disorder of the plantar fascia with an unknown etiology. The main clinical characteristics include slow growing nodules on the medial and central bands of the plantar fascia, which may become painful and negatively affect ambulation. Most established conservative therapies today target symptomatic relief. As symptoms progress, therapies such as injections, shockwave ablation, radiation, and/or surgery may be required. This review aims to provide insight into the pathophysiology of this condition in addition to detailing current and investigational therapies for this disorder. Many therapies have been proven in similar conditions, which could lead to promising treatment options for plantar fibromatosis.

LEVELS OF EVIDENCE

Level V: Expert opinion.

Evidence-Based Management Guidelines on Peyronie's Disease

INTRODUCTION

Despite recent advances in our knowledge and treatment strategies in Peyronie's Disease (PD), much remained unknown about this disease.

AIM

To provide a clinical framework and key guideline statements to assist clinicians in an evidence-based management of PD.

METHODS

A systematic literature search was conducted to identify published literature relevant to PD. The search included all relevant articles published up to June 2015, including preclinical studies and published guidelines. References used in the text were assessed according to their level of evidence, and guideline recommendations were graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Owing to the paucity of larger series and randomized placebo-controlled trials with regard to surgical intervention, guideline statements are provided as clinical principle or expert opinion.

MAIN OUTCOME MEASURES

This literature was discussed at a panel meeting, and selected articles with the highest evidence available were used to create consensus guideline statements for the Fourth International Consultation on Sexual Medicine guidelines on PD.

RESULTS

In addition to existing Third International Consultation on Sexual Medicine guidelines on PD, seven new summary recommendations were created.

CONCLUSION

A greater understanding of the scientific basis of PD is greatly needed to address our understanding of the pathophysiology, clinical epidemiology, psychosocial, and diagnostic assessment as well as treatment strategies.

A meta-analysis of extracorporeal shock wave therapy for Peyronie's disease

The efficiency of extracorporeal shock wave therapy (ESWT) for Peyronie's disease (PD) has been controversial for a very long time. We aimed to evaluate the efficiency of ESWT for PD and provide possible evidence on the basis of a meta-analysis of existing comparative studies. All controlled studies, including randomized controlled trials (RCTs), cohort studies and case-control studies, that focused on the efficiency of ESWT for PD, were prospectively identified through comprehensive searches of PubMed, the Cochrane Library and Embase databases. We conducted a meta-analysis of these studies. Six studies including 443 patients were selected for the meta-analysis. Pooling data of these studies showed that ESWT could significantly increase the percentage of men with lessening of penile plaques (odds ratio (OR) 2.07, 95% confidence interval (CI) 1.11-3.85, P=0.02), relief of pain (OR 4.46, 95% CI 2.29-8.68, P<0.0001) and complete remission of pain (OR 5.86, 95% CI 2.66-12.92, P<0.0001). However, insignificant differences were found in improvement of penile curvature (OR 1.88, 95% CI 0.97-3.65, P=0.06) and sexual function (OR 2.22, 95% CI 0.69-7.11, P=0.18) between ESWT and placebo groups. Further, similar results were shown for sensitivity and publication bias analysis when only RCTs were included. However, sporadic complications caused by ESWT were reported, but no patient needed additional treatment aside from conservative observation. ESWT may be an effective and safe treatment for lessening of penile plaques and relieving pain for men with PD, but not for improving of penile curvature and sexual function.

Extracorporeal shock wave therapy (ESWT) in urology: a systematic review of outcome in Peyronie's disease, erectile dysfunction and chronic pelvic pain

PURPOSE

The objective was to evaluate high-level evidence studies of extracorporeal shock wave therapy (ESWT) for urological disorders.

METHODS

We included randomized controlled trials reporting outcomes of ESWT in urology. Literature search on trials published in English using EMBASE, Medline and PubMed was carried out. The systematic review was performed according to PRISMA guidelines.

RESULTS

We identified 10 trials on 3 urological indications. Two of 3 trials on Peyronie's disease (PD) involving 238 patients reported improvement in pain; however, no clinical significant changes in penile deviation and plaque size were observed. Four studies on erectile dysfunction (ED) including 337 participants were included. Using International Index of Erectile Function (IIEF-EF) and erectile hardness scale (EHS) data suggested a significant positive effect of ESWT in phosphodiesterase-5 inhibitor (PDE-5i) responders in 2 of 4 trials and 3 of 4 trials, respectively. Three studies on chronic pelvic pain (CPP) engaging 200 men reported positive changes in National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). There was considerable heterogeneity between trials both with regard to treatment techniques and outcome measures, making it difficult to compare results.

CONCLUSIONS

ESWT may resolve pain in PD patients, while evidence for reducing curvature and plaques size is poor. Effects of ESWT on IIEF in ED patients are inconsistent; however, data on EHS does imply that the treatment potentially may recover natural erection in PDE-5i responders. ESWT seems to be able to resolve pain in CPP patients in the short term. In all three disease entities, long-term outcome data are still warranted.

Peyronie's disease: What's around the bend?

INTRODUCTION

Peyronie's disease (PD) is a fibrotic diathesis of the tunica albuginea that results in penile plaque formation and penile deformity, negatively affecting sexual and psychosocial function of both patients and their partners. In this review, we discuss the PD literature and PD treatment options, with special emphasis on potential future therapies.

METHODS

The PD literature was reviewed, and articles of interest were identified using keyword search in PubMed. Articles evaluating investigational and novel PD treatments were emphasized.

RESULTS

Existing PD treatment modalities are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Surgical treatment has high success rates and is indicated in men with significant, stable deformity. The United States Food and Drug Administration-approved intralesional collagenase Clostridium histolyticum injection therapy is a minimally invasive option with demonstrated efficacy in PD. Other nonsurgical therapies have been reported, including Botox and stem cell therapy, but these currently have little or equivocal evidence to support their efficacy.

CONCLUSIONS

Further research is essential to develop novel, safe, and effective minimally invasive PD treatment options. This work is ongoing, with the promise of specific, targeted, and highly effective therapies on the horizon.

Stromal Vascular Fraction Combined with Shock Wave for the Treatment of Peyronie's Disease

BACKGROUND

This pilot study was used to evaluate safety and subjective outcomes in a small series of Peyronie's disease patients using a combination of autologous stromal vascular fraction (SVF) and penile shock wave treatments. SVF can be procured and deployed into Peyronie's plaques, enabling the surgeons to procure and mobilize significant numbers of both adult mesenchymal stem cells and antiinflammatory cytokines released from the adipose collagen matrix after collagen digestion. Penile shock wave therapy stimulates targeted tissues and may activate stem cells found in the SVF and promote healing and fibrosis mitigation.

METHODS

SVF isolated from lipoaspirate was deployed by injection into 11 patients with Peyronie's plaques in combination with a series of shock wave treatments. Subjective outcomes tests performed at baseline and at 6 months included the Erectile Hardness Grading Score and the Peyronie's Disease Questionnaire (Questions 1-6).

RESULTS

All patients noted subjective improvement in curvature and subjective reduction in plaque size. Seven patients reported improvement in erectile function. Mean Erectile Hardness Grading Score increased from 2.7 to 3.5, and mean Peyronie's Disease Questionnaire scores decreased from 15.0 to 8.7.

CONCLUSIONS

SVF is known to have scar mitigation, antiinflammatory, immunomodulatory, and regenerative effects, and it has been used for a variety of conditions on an investigational basis. SVF containing mesenchymal stem cells can be procured in a closed surgical system from lipoaspirate in a same-day setting and deployed directly into Peyronie's plaques in combination with penile shock wave therapy resulting in plaque mitigation.

Peyronie's disease and low intensity shock wave therapy: Clinical outcomes and patient satisfaction rate in an open-label single arm prospective study in Australian men

Purpose

To evaluate the efficacy, safety and patient satisfaction outcomes following low intensity extracorporeal shock wave therapy (LiESWT) in men with Peyronie's disease (PD) using a standardised protocol.

Materials and Methods

In this open-label single arm prospective study, patients with PD were enrolled following informed consent. Patient demographics, change in penile curvature and plaque hardness, International Index of Erectile Function (IIEF)-5 score, and overall satisfaction score (on a 5-point scale) were recorded. Treatment template consists of 3000 shock waves to the Peyronie's plaque over 20 minutes, twice weekly for 6 weeks.

Results

The majority of patients have PD history longer than 6 months (mean, 12.8 months; range, 6-28 months). Two thirds of patients have received and failed oral medical therapy. There were improvements in penile curvature (more than 15 degrees in 33% of men), plaque hardness (60% of men) and penile pain (4 out of 6 men) following LiESWT. There was a moderate improvement in IIEF-5 score (>5 points reported in 20% of men). No complication was reported and the majority of patients were satisfied (rated 4 out of 5; 70% of men) and would recommend this therapy to others.

Conclusions

In a carefully selected group of men with PD, LiESWT appears to be safe, has moderate efficacy and is associated with high patient satisfaction rate in the short term.

All about Peyronie's disease

Peyronie's disease (PD) is an acquired connective tissue disorder of the tunica albuginea of the corpus cavernosum, characterized by excessive fibrosis and plaque formation. PD can result in significant physical and psychological morbidity; as it may prevent intercourse and cause adverse impacts on partner relationships. The exact etiology and pathophysiology remain unclear, and many misconceptions about the disease associations, course and treatment exist.

The disease has two distinct stages. The acute stage is characterized by pain, and disease may progress during this stage. Non-surgical managements at this stage aim to alleviate pain and stabilize the disease. Results for non-surgical treatment are often conflicting. The chronic stage occurs 6–12 months later, where pain disappears and the deformity stabilizes. Surgical treatment is reserved for significant deformity or with inability to penetrative intercourse. The choice of the surgical technique depends on the length of the penis, degree of deformity, erectile function, patients' expectations and surgeon's preference.

PEYRONIE'S DISEASE: A REVIEW OF ETIOLOGY, DIAGNOSIS, AND MANAGEMENT

Peyronie's Disease (PD) is a superficial fibrosing disorder of the penis resulting in plaque formation and penile deformity. Once considered rare, PD has more recently been found in up to 13% of men, and can negatively affect sexual and psychosocial function of both patients and their partners. While the etiology of PD is unclear, it is thought to result from an inciting traumatic event followed by aberrant fibrosis or dysregulated wound healing. The evaluation of men presenting with PD includes a detailed history and physical exam, focusing on the penis in both the flaccid and erect states. PD is often associated with erectile dysfunction (ED), as well as several other comorbidities. Laboratory testing is not needed to diagnose PD, although given the associations between PD and systemic diseases including hypogonadism, diabetes, and cardiovascular disease, screening and work-up for these conditions in men with PD may be warranted. Treatment modalities for PD are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Oral, topical, and mechanical therapies generally have little evidence supporting their efficacy. Several intralesional therapies, including interferon α2b and collagenase Clostridium hystiolyticum have demonstrated efficacy in the treatment of PD. Surgical treatment, indicated in men with significant, stable deformity, includes plication of the tunica albuginea, plaque incision/excision and grafting, and placement of inflatable penile prosthesis (IPP) with or without additional maneuvers to achieve desired results, and has high success rates.

A first prospective, randomized, double-blind, placebo-controlled clinical trial evaluating extracorporeal shock wave therapy for the treatment of Peyronie's disease

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is a conservative therapy for patients with Peyronie's disease (PD).

OBJECTIVE

To investigate the effects of ESWT in patients with PD.

DESIGN, SETTING, AND PARTICIPANTS

One hundred patients with a history of PD not >12 mo who had not had previous PD-related treatments were enrolled in a prospective, randomized, double-blind, placebo-controlled study. Patients were randomly allocated to either ESWT (n=50) or placebo (n=50). Erectile function (EF), pain during erection, plaque size, penile curvature, and quality of life (QoL) were assessed at baseline, at 12 wk, and at 24 wk follow-up.

INTERVENTION

Four weekly treatment sessions were administered. Each ESWT session consisted of 2000 focused shock waves. For the placebo group, a nonfunctioning transducer was employed.

MEASUREMENTS

EF was evaluated with the shortened version of the International Index of Erectile Function (IIEF-5), pain was evaluated with a visual analog scale (VAS; 0-10), plaque size was measured in cm(2), and penile curvature was measured in degrees.

RESULTS AND LIMITATIONS

After 12 wk, mean VAS score, mean IIEF-5 score, and mean QoL score ameliorated significantly in patients receiving ESWT. Mean plaque size and mean curvature degree were unchanged in the ESWT group, while a slight increase was reported in the placebo group (p-value not significant vs baseline). After 24 wk, mean IIEF-5 score and mean QoL score were stable in the ESWT group, while mean VAS score was significantly lower when compared with baseline in both groups. Interestingly, after 24 wk, mean plaque size and mean curvature degree were significantly higher in the placebo group when compared with both baseline and ESWT values. The main limitations were that the QoL questionnaire was not validated, ED was not etiologically characterized, and inclusion criteria were restricted.

CONCLUSIONS

In patients with PD, ESWT leads to pain resolution and ameliorates both EF and QoL.

Extracorporeal Shock Wave Therapy as First Line Treatment in Patients with Peyronie's Disease

Introduction

Extracorporeal Shock Wave Therapy (ESWT) is a minimal invasive treatment for patients with Peyronie's Disease (PD). Currently, however, controversial data exist on the efficacy of ESWT as first-line treatment.

Methods

We performed a prospective, randomized, double blind, placebo-controlled trial to evaluate the efficacy of ESWT in a group of 100 patients with disease duration <12 months, naive to previous treatments, with a single plaque, erectile dysfunction and/or painful erections and/or penile recurvatum. Patients were randomized to undergo ESWT or Placebo. The Storz Duolith device was employed for treatments. A non-functioning probe was employed as placebo. Treatments were administered in four sessions at weekly intervals. The following evaluations were performed at baseline and at 12- and 24-week intervals from treatment: IIEF-5 (International Index of Erectile Function) questionnaire, VAS (Visual Analogue Scale), plaque size measurement, penile curvature measurement.

Results

Only patients treated with ESWT reported a significant improvement of mean VAS score and of mean IIEF-5 score at a 12-week follow-up. Mean plaque size and mean curvature degree did not improved significantly in patients treated with ESWT but showed a significant worsening at the 24-week follow up compared to baseline values in the placebo group.

Conclusions

ESWT can improve significantly painful erections and erectile functions in patients with PD naive to other treatments. Moreover, ESWT can stabilize plaque size and penile curvature thus preventing disease progression.

Long-term results of extracorporeal shockwave therapy for Peyronie's disease

PURPOSE

To analyze the long-term results in patients undergoing extracorporeal shockwave therapy (ESWT) for Peyronie's disease.

PATIENTS AND METHODS

Patients treated with ESWT (3000 shockwaves on a Storz Minilith SL lithotripter) for Peyronie's disease were included. The mean disease duration prior to treatment was 23.2 months (range 4-60 months). Penile angulation was measured before and after treatment by artificial vacuum induction of erection. Pain during erection was measured using a visual analog scale (VAS 0-5). The average number of ESWT sessions was 3.4 (range 2-9). The mean follow-up post-treatment was 44.1 months (range 42-48 months). Of 44 eligible patients, 38 patients (86.4%) were contactable for evaluation.

RESULTS

Of the 38 patients, 10 (26%) subsequently underwent corrective surgery for failed ESWT. Of the remaining 28 patients, 18 (47% of the total) had a statistically significant reduction in angulation, with a mean reduction of 33.2 degrees +/- 14.4 degrees (SD) (range 10 degrees -75 degrees ) (P < 0.001). Nine patients (24%) obtained no benefit, and one had an increase in angulation of 10 degrees . Of the 24 patients with pain, 16 (66.6%) reported relief after ESWT, the mean reduction being 2.5 (range 0.5-4.0) on the VAS (P < 0.001). Of the 28 patients who had not undergone surgical correction, 18 (65%) reported erections suitable for intercourse; 14 (48%) were satisfied with ESWT, 8 (30%) dissatisfied, and 6 (22%) uncertain. Although one patient complained of some penile shortening, no other long-term adverse events were noted.

CONCLUSION

Although a quarter of ESWT patients resorted to surgery, in the absence of other effective nonsurgical treatments, ESWT may provide a useful, safe, conservative management option. Extracorporeal shockwave therapy cannot yet be recommended as standard for Peyronie's disease, and randomized controlled studies are required to validate its efficacy and identify the subset of patients most likely to benefit.

The medical management of Peyronie's disease

There are a wide variety of medical treatments that are available to the practicing urologist, including oral agents, topical creams and gels with or without iontophoresis, intralesional injection therapy, radiation therapy, extracorporeal shockwave therapy, and laser therapy. Medical management of Peyronie's disease might be a valuable treatment option for this debilitating disorder, especially in the early symptomatic stages of the disease. Although no single modality has been demonstrated to have superior efficacy, intralesional therapy appears to confer some benefit. Multicenter, large-scale, randomized, controlled studies are necessary to fully establish the efficacy of the available treatments. Until such trials are conducted, a rational approach involving combination therapy is the most appropriate method to treat these patients. In this Review, the current medical treatment options available for the management of Peyronie's disease are discussed and a management algorithm is proposed.

Extracorporeal shockwave therapy for Peyronie's disease: an alternative treatment?

AIM

To determine retrospectively the safety and efficacy of extracorporeal shock wave therapy (ESWT) in patients with Peyronie's disease.

METHODS

Fifty-three patients with stable Peyronie's disease underwent ESWT (group 1). Fifteen patients matched with the baseline characteristic of the patients in group 1, who received no treatment, were used as the control (group 2). The patients' erectile function (International Index of Erectile Function [IIEF-5] score), pain severity (visual analog scale), plaque size and degree of penile angulation were assessed before and after the treatment in group 1 and during the follow-up in group 2.

RESULTS

The mean follow-up time was 32 months (range: 6-64 months) in group 1 and 35 months (range: 9-48 months) in group 2. All the patients were available for the follow-up. Considering erectile function and plaque size, no significant changes (P > 0.05) were observed in group 1 before or after the ESWT. A total of 39 patients (74%) reported a significant effect in pain relief in group 1 after ESWT. However, regarding improvement in pain, IIEF-5 score and plaque size, no significant differences were observed between the two groups. In 21 patients (40%) of group 1, the deviation angle was decreased more than 10 degrees with a mean reduction in all patients of 11 degrees (range: 6-20 degrees). No serious complications were noted considering ESWT procedure.

CONCLUSION

ESWT is a minimally invasive and safe alternative procedure for the treatment of Peyronie's disease. However, the effect of ESWT on penile pain, sexual function and plaque size remains questionable.

Extracorporeal Shockwave Therapy for Peyronie's Disease: Who Benefits?

BACKGROUND AND PURPOSE

Extracorporeal shockwave therapy (ESWT) has been reported to improve the symptoms of Peyronie's disease. However, the response rates to this treatment appear to be variable. This study aimed to determine whether any patient or plaque characteristics are associated with a better outcome.

PATIENTS AND METHODS

A series of 36 patients with Peyronie's disease received ESWT as a primary treatment. Subjective response rates were compared on the basis of patient age, degree of pretreatment penile curvature, predisposing medical factors, duration of disease, and extent of plaque calcification.

RESULTS

Ten men (27.8%) reported subjective improvements in curvature after ESWT. Of the factors considered, only age and pretreatment curvature influenced outcomes: 50% of the men below the mean age reported improvement compared with 5.6% of older men and 62.5% of men with mild curvature reported improvement compared with 8.3% of those with severe curvature.

CONCLUSION

The response to EWST is not the same for all men with Peyronie's disease. Younger men and those with milder curvature have the best outcomes.

Extracorporeal shockwave therapy for Peyronie's disease does not correct penile deformity

To evaluate whether extracorporeal shockwave therapy (ESWT) offers an effective treatment for the main complications of Peyronie's disease (PD), that is, penile deformity and angulation, painful erection and most importantly unsatisfied sexual intercourse. From September 1999 to January 2001, 52 patients with PD were treated with ESWT. Pain during erection was assessed with a visual analogue scale. Penile deviation was determined by photographs with a goniometer. Five treatment sessions were performed at weekly intervals. Each consisted of 3000 shockwaves with an emission frequency of 120 shockwaves/min and a mean intensity of 0.17 mJ/mm(2). A Storz Minilith SL 1 with integrated inline ultrasound probe was used. In all, 52 patients were evaluated 6 weeks after ESWT for early follow-up. Before ESWT intercourse was difficult or impossible for 40 men; 29 patients suffered mainly from penile deformity, 14 from painful erection and eight mainly from loss of distal rigidity. A total of 30 patients mentioned painful erection before treatment. In 28 patients (93%) pain reduction was achieved. A total relief of pain was observed in 19 patients (63%). Mean pain score dropped from 4.2 to 1.3 in patients who suffered predominantly from painful erections. Intercourse satisfaction improved in 11 patients after therapy. Mean angulation before (40 degrees ) and after (37 degrees ) ESWT did not change significantly. Late follow-up after 11.1 months (4-17 months) could be completed in 36 patients. In total, 19 men reported that ESWT improved their PD. Of these, 16 noted no change. Only one of the patients noticed a worsening of his disease during or after treatment. Complication rate was low with only minor side effects such as minimal skin bruising; one urethral bleeding occurred. ESWT did reduce pain during erection in patients suffering mainly from painful erection due to PD. However, penile angulation did not improve significantly in our setup and thus intercourse difficulties did improve only in 28% of the patients. Therefore, we do not recommend ESWT as a primary treatment for PD.

Shockwave Therapy as First-Line Treatment for Peyronie's Disease: A Prospective Study

BACKGROUND AND PURPOSE

To assess in a prospective study whether shockwave therapy (SWT) is effective as a first-line treatment for Peyronie's disease.

PATIENTS AND METHODS

Forty patients with previously untreated Peyronie's disease underwent SWT with the Epos overhead-module device (Dornier). The pain severity (visual analog pain scale [VAS] 0-5), the degree of penile angulation after vasoactive drug injection, plaque size by ultrasound measurement, and erectile dysfunction (IIEF score) were assessed prior to and after treatment. Of the 40 patients, 7 underwent two sessions and the rest three sessions. The time interval between treatments was 2 weeks. At a power level of 2 to 5 (mean 4), a maximum of 3000 shockwaves per plaque per treatment were applied. The mean follow-up was 12 months.

RESULTS

All patients completed the protocol. The tolerance and safety were excellent. Of the 25 patients with pain on erection, 12 (48%) noticed relief after the first session, while 9 more were pain free at the end of the treatment (VAS reduction 2.8; P<0.0001, and 2; P<0.001, respectively). For 25 patients (62.5%), an improvement in penile angulation>20 degrees was observed, with a mean reduction of 35 degrees (range 20 degrees-60 degrees ) (P<0.001). No significant change in plaque size was noted. Among 28 patients with erectile dysfunction, 18 (64.2%) had a marked increase in erection quality (IIEF score change: +4 for 10 patients, +6 for 4 patients, +8 for 2 patients, +9 for 2 patients).

CONCLUSION

Our results support SWT as an effective and safe first-line treatment for Peyronie's disease.

An alternative non-invasive treatment for Peyronie's disease

OBJECTIVE

Surgical correction of the deformity and plaque caused by Peyronie's disease has some important disadvantages and extracorporeal shockwave therapy (ESWT) emerged as a new promising therapy. We evaluated prospectively the efficacy and safety of the association of high dose vitamin E and ESWT as a non-invasive treatment for the disease.

MATERIALS AND METHODS

Twenty-five patients 42 to 68 years old (mean = 54) presenting penile deviation and sexual distress caused by Peyronie's disease were treated in a non-invasive manner. The time of penile deviation ranged from 16 to 52 months (mean = 30). All patients had previous unsuccessful treatment for Peyronie's disease. The angulation's deformity of the penis was assessed by photography at home. The patients received vitamin E (l.200 mg daily) during 3 months and underwent 3 to 6 sessions (mean = 3) of ESWT (3,000 to 4,000 shockwaves) at a power level of l to 2 at 1-week intervals.

RESULTS

From 25 patients treated, 16 (64%) reported an improvement in penile angulation, with a mean reduction of 21 degrees (10 to 40). Eight patients reported improvement in their spontaneous erections. Overall, the patients presented only minimal bruising at the site of treatment and skin hematoma. Four patients presented urethral bleeding. The mean angulation after treatment in the control group was 48.67 degrees (30 - 70) and in the study group was 24.42 degrees (0 - 70), statistically significant.

CONCLUSION

Considering the common complications and the unsatisfactory outcome of the surgical correction for Peyronie's disease, the association of high dose vitamin E and ESWT represents a good option for a non-invasive, effective and safe treatment of the penile deformity.

Peyronie's disease: an update of the medical management

Peyronie's disease (PD) is characterised by penile plaque formation, pain, penile deformity and erectile dysfunction. It is a fibrotic disorder of the tunica albuginea with a poorly understood aetiology and epidemiology. PD may be classified into inflammatory (acute) and chronic stages. Medical treatment is usually instigated during the inflammatory phase of the disease. A review of the literature reveals a wide range of oral, intralesional and alternative therapies that are discussed in relation to established pathophysiological mechanisms of the disease. The advantages and disadvantages of each treatment are summarised. This review also discusses the ongoing therapeutic dilemmas of PD and suggests a treatment strategy based on an analysis of the urological literature.

Extracorporeal shock wave therapy for Peyronie's disease: exploratory meta-analysis of clinical trials

PURPOSE

Extracorporeal shock wave therapy (ESWT) for the treatment of Peyronie's disease is still controversial. This exploratory meta-analysis of published studies in the international literature investigates its therapeutic effects.

MATERIALS AND METHODS

The treatment outcomes from 17 study groups identified by a computerized literature search were compared with natural history outcomes and data from control groups from 2 controlled ESWT studies. An exploratory meta-analysis was performed because a methodologically sound meta-analysis lege artis did not appear appropriate, since treated groups differ considerably in structure, the selection of outcome measures is inconsistent and measurement is not standardized.

RESULTS

ESWT seems to have an effect on penile pain during erection and on the improvement of sexual function. Pain seems to resolve faster after ESWT than during the course of the natural history. The effect on plaque size and penile curvature is less impressive.

CONCLUSIONS

ESWT in Peyronie's disease at least seems to be effective in regard to penile pain and sexual function compared to natural history. Deducing from these data the effect on plaque size and curvature remains questionable. However, ESWT is not an evidence based therapy at present. A controlled (preferably pairwise matched), single blind, multicenter study with careful, detailed documentation of disease symptoms before intervention and of outcomes is required to evaluate the real effect of ESWT.

Therapeutic effects of colchicine in the management of Peyronie's disease: a randomized double-blind, placebo-controlled study

To determine effectiveness and safety of colchicine in Peyronie's disease. In all, 84 patients with Peyronie's disease who did not have calcified plaque were entered into study. The mean disease duration was 15 months. A medical history was obtained, and physical examination, penile X-ray, and dynamic penile duplex ultrasound were performed. Patients were randomly divided into group 1, those who received 0.5-2.5 mg colchicine daily for 4 months and group 2, who received placebo for the same period. Response to therapy was assessed objectively, during dynamic penile duplex ultrasound, as well as subjectively using International Index of Erectile Function (IIEF) questionnaire and measurements of pain, duration of disease, penile curvature, and plaque size. Differences before and after treatment and among the three Kelami classification groups were assessed. In total, 78 (92.8%) completed the whole treatment schedule. Pain resolved in 60 and 63.6% of the patients treated with colchicine and placebo, respectively (P > 0.05). After therapy, in subjects and controls a reduction in the penile deformity was observed by 17.1 and 18.4% of the patients (P > 0.05), and a decrease in plaque size was noticed by 10.5 and 10%, respectively (P > 0.05). Objective measurements did not demonstrate any difference in plaque size or penile curvature. There were no substantial differences in response to treatment based on duration of disease or within the three Kelami classification groups. Significant drug-related adverse effects occurred in colchicine group and in two cases was treatment discontinued. Colchicine is no better than placebo in improvement of pain, curvature angle, or plaque size in patients with Peyronie's disease.

Questionable Efficacy of Extracorporeal Shock Wave Therapy for Peyronie’s Disease:: Results of a Prospective Approach

PURPOSE

Extracorporeal shock wave therapy (ESWT) for Peyronie's disease is still a topic of debate. We evaluated the effects of ESWT in a large series of patients with Peyronie's disease via a prospective approach.

MATERIALS AND METHODS

In a prospective study 114 patients with Peyronie's disease were treated with ESWT. Baseline and followup examinations included ultrasound, and measurement of plaque size and curvature. Symptomatology was evaluated based on a standardized interview. A Minilith SL1 (Storz Medical AG, Kreuzlingen, Switzerland) lithotriptor was used with 4,000 shock waves at a maximum energy level of 0.17 mJ/mm2 applied per session.

RESULTS

A total of 96 patients were available for followup. Considering the total study group no significant changes in penile curvature, plaque size or sexual function were observed despite significant improvements in patients with a curvature of 31 to 60 degrees. Penile pain ceased in 76% of the affected patients.

CONCLUSIONS

According to our data ESWT does not appear to be significantly effective for decreasing penile curvature and plaque size or improving sexual function in the total population of patients with Peyronie's disease despite improvements in individuals. Penile pain seems to resolve earlier than during the natural course. Regarding the results of this study and previous reports with exact documentation of the clinical findings it can be concluded that ESWT cannot be recommended as a standard procedure for Peyronie's disease. To evaluate the exact efficacy of ESWT a controlled, single-blind, multicenter study with exact documentation of symptoms is urgently required.

Extracorporeal shockwave therapy for peyronie disease

While surgery is the mainstay of therapy for Peyronie disease requiring correction of angulation, interest has grown in the application of extracorporeal shockwave therapy (ESWT) as a minimally invasive approach. This article reviews the current literature reporting the use of ESWT for Peyronie disease.

Objective and subjective changes in patients with Peyronie's disease after management with shockwave therapy

BACKGROUND AND PURPOSE

Very few reports have been published on the management of Peyronie's disease by shockwave therapy. Existing publications on this topic are based on subjective improvement described by the patients themselves. Our aim was to determine objectively the effect of shockwave therapy on the signs and symptoms caused by Peyronie's disease.

PATIENTS AND METHODS

To date, 65 patients (age 58.4 +/- 8.7 years) have been enrolled in a therapeutic pilot study. The disease duration was 33.7 +/- 42.9 months. Inclusion criteria were palpable plaque together with deviation, pain (visual pain scale), or loss of distal rigidity. Clinical examination (prior to first therapy and 1, 6, and 18 months after last shockwave delivery) included palpation and sonography of the plaque (mean surface size 2.2 +/- 1.1 cm(2)), measurement of deviation, assessment of pain and distal loss of rigidity (artificial erection induced by intracavernosal injection of 5 microg of alprostadil [Caverject]). Shockwaves (1,000 impulses at 12 kV per square centimeter of plaque) were delivered to the nonerect penis once a week for a period of 5 weeks with the Minilith; Storz Medical.

RESULTS

Eighteen months (N = 35) after the last shockwave session, the deviation angle had decreased from 59.3 degrees +/- 38.1 degrees to 49.3 degrees +/- 32.5 degrees (N = 24; P = 0.1496). Pain during erection disappeared in 15 of 17 patients and was reduced in 1 other patient (P < 0.0001). There was no effect on distal rigidity in any patient. Six patients achieved satisfactory sexual intercourse (vaginal penetration) before and 15 patients after shockwave therapy. The adverse effects were small skin hematomas in 90% of patients and initial transient macrohematuria in 30%.

CONCLUSION

Our study demonstrates objective and subjective changes in patients with Peyronie's disease after shockwave therapy. Artificial erection served as a control to assess improvement of the deviation angle.

Evaluation of extracorporeal shock wave therapy in Peyronie's disease

OBJECTIVES

To evaluate the results of extracorporeal shock wave therapy (ESWT) in patients with Peyronie's disease.

METHODS

This study included 42 patients (mean age 55.4 years, range 32 to 72, SD 9.92) with Peyronie's disease. The mean duration of disease was 16.5 months (range 3 to 60, SD 13.31). Before treatment, the degree of angulation was assessed artificially by injection of 10 to 20 microg alprostadil, and Polaroid photographs were taken. Patients were also questioned about pain on erection, whether sexual intercourse was possible, and the quality of erections. All were initially treated with three sessions of ESWT (3000 shock waves). After three sessions, patients who believed that improvement had resulted or who wanted to undergo additional treatment went on to have further sessions. The mean duration of follow-up was 5.9 months (range 2 to 18, SD 4.4), after which the results were analyzed.

RESULTS

Those who believed that improvement in angulation had resulted were asked to provide Polaroid photographs to assess the improvement objectively. Six (14%) said that they had excellent results, 21 (50%) had significant improvement, 7 (17%) had slight improvement, and 8 (19%) had no change. Of the 25 who had pain on erection before treatment, 21 (84%) reported complete or near complete relief after treatment. Five patients said that the quality of the erections had improved after treatment. Eight patients complained of mild and one of severe pain during or immediately after treatment; 2 of these 9 patients had both pain and bruising.

CONCLUSIONS

The initial results with ESWT are promising, with minimal complications. The long-term results need to be evaluated.

New advances in Peyronie's disease

The formation of Peyronie's disease plaques is a process that seems to involve a cascade of genetic, structural and immunologic events. Clinical manifestations include penile deformity and possible erectile dysfunction. Rational strategies have been forthcoming, with both minimally invasive and surgical treatments of Peyronie's disease available. This article reviews and updates current scientific and clinical advances in Peyronie's disease.

Peyronie's disease-the Plymouth experience of extracorporeal shockwave treatment

OBJECTIVE

To describe our experience of the use of extracorporeal shockwave treatment (EST) for Peyronie's disease. Patients and methods The study included 28 patients (mean age 57 years, range 34-72) with stable Peyronie's disease who were treated with 3.9 (3-5) sessions of EST to the Peyronie's plaque. The patients' erectile function, pain and penile angle were assessed before and after treatment with EST.

RESULTS

Of the 28 patients, 20 felt that their erection improved after the procedure; 11 patients were able to recommence sexual intercourse and the index of erectile function increased in all but one patient. Conclusion EST produces a significant improvement in pain and penile angle, with no serious complications.