A review of the epidemiology and treatment of Peyronie's disease

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.

Comparative outcomes of intralesional collagenase injection for Peyronie's disease: acute vs. stable phase treatment

Collagenase clostridium histolyticum (CCH) was FDA-approved for treating Peyronie's Disease (PD), demonstrating significant curvature improvement in patients during the stable phase of disease. In this retrospective cohort study, we aimed to assess the safety and effectiveness of intralesional CCH injections during the acute phase of PD. We retrospectively evaluated all men who received intralesional CCH for PD at a single academic institution between July 2017 and January 2023, focusing on patient demographics, comorbidities, pre- and post-treatment curvature, and adverse events. Patients in the acute phase had symptoms for ≤ 12 months with penile pain and/or curvature changes. A total of 100 patients treated with intralesional CCH injections for PD were included. Percent change in penile curvature was not significantly different between acute and stable phases (37.02 vs. 34.01%, p = 0.57). A total of 55 patients (76.39%) in the stable phase and 23 patients (82.14%) in the acute phase showed improvement in curvature, with no significant differences in curvature outcomes or adverse events between the two groups. This study contributes to the growing evidence that intralesional CCH treatment during the acute phase of PD is safe and effective.

Fractional CO2 laser for the treatment of Peyronie's disease A pilot clinical trial

INTRODUCTION

Fractional CO2 laser therapy is used to treat fibrosing conditions similar to Peyronie's disease (PD). The aim of the study was to evaluate the safety and efficacy of using a fractional CO2 laser in the management of chronic phase PD.

METHODS

This was a single-site, non-randomized, open-label study using a fractional CO2 laser. Subjects underwent three treatment sessions every six weeks with a fractional CO2 device. Topical triamcinolone was applied immediately after each treatment. Between treatments, patients performed penile modeling three times daily. Penile curvature assessments, self-reported questionnaires, and adverse event screenings were completed at baseline, 24 weeks, and 52 weeks.

RESULTS

Five patients were included in the study. The median baseline penile curvature was 37.0° (interquartile range [IQR] 33.0°, 53.0°), and at 52 weeks, this had reduced to a median curvature of 28.0° (IQR 17.50°, 44.0°, p=0.03), representing a median reduction in penile curvature by 24.3% (IQR 17.0%, 47.5%). The International Index of Erectile Function Overall scores were comparable at baseline and at 52 weeks (median 59.0, IQR 42.5, 66.5 vs. median 60.0, IQR 53.5, 70.0 respectively, p=0.81). Patients did report significant improvement in overall Peyronies' Disease Questionnaire scores from baseline to 52 weeks after laser treatment (median 26.0, IQR15.0, 29.5, vs. median 14.0, IQR 7.0, 22.50, respectively, p=0.03). Four patients reported self-limiting side effects immediately after laser therapy that resolved spontaneously within two weeks.

CONCLUSIONS

With encouraging results at 52 weeks, fractional CO2 laser therapy may serve as a well-tolerated and minimally invasive therapy for PD in the future.

The Emerging Role of Artificial Intelligence and Automated Platforms for the Assessment of Penile Curvature: A Scoping Review

PURPOSE OF THE REVIEW

The estimation of penile curvature is an essential component in the assessment of both Peyronie's disease and hypospadias-associated congenital penile curvature, as the degree of curvature can significantly impact treatment decision-making. However, there is a lack of standardization in curvature assessment and current methodologies are prone to inaccuracies. With the rise of artificial intelligence (AI) in urology, new research has explored its applications in penile curvature assessment. This review aims to evaluate the current uses of AI and other automated platforms for assessing penile curvature.

RECENT FINDINGS

Several novel and promising tools have been developed to estimate penile curvature, some utilizing AI-driven models and others employing automated computational models. These platforms aim to improve curvature assessment in various settings, including at-home evaluation of Peyronie's disease, in-office assessments using three-dimensional (3D) methodologies, and preoperative evaluations for hypospadias repair. In general, these new platforms produce highly accurate and reproducible angle estimates in non-clinical studies, however their effectiveness and relation to patient outcomes has had limited evaluation in clinical settings. Significant advancements have been made in the assessment and estimation of penile curvature in both Peyronie's and pediatric patients, largely driven by AI and other automated platforms. Continued research is needed to validate these findings in clinical studies, confirm their efficacy, and assess their feasibility for real-world applications.

Outcomes of surgical correction of Peyronie's disease with plaque excision and grafting: Comparison of testicular tunica vaginalis graft versus bovine pericardium graft

Objective

Peyronie's disease (PD) is an abnormal wound healing in the penile tunica albuginea. After fibrotic plaque excision, different graft materials have been used to repair the defects, but the optimal graft remains unknown. This study aimed to compare the functional outcomes of testicular tunica vaginalis grafts and bovine pericardium grafts in patients with severe PD.

Methods

A retrospective comparative study was conducted on 33 PD patients undergoing partial plaque excision and grafting from September 2015 to May 2021. The patients were divided into two groups depending on the type of graft used. For 15 patients in Group B, testicular tunica vaginalis grafts were used to repair the defect, while for 18 patients in Group A, bovine pericardium grafts were used. Data of the patient's age, comorbidities, sexual function, penile curvature, postoperative complications, need for further treatment, change in penile length, and satisfaction were gathered and compared between the groups. Sexual function was evaluated using the 5-item version of the International Index of Erectile Function (IIEF-5), and a functional less than 20-degree penile curvature after surgery was considered a successful intervention.

Results

There was no difference in age, comorbidities, degree of curvature, perioperative IIEF-5, operative time, plaque size, or complication rates. After surgery, a statistically significant improvement in curvature degree (p<0.05) and satisfactory penile appearance (p<0.05) were seen in both groups without any superiority between the two groups (p=0.423 and p=0.840, respectively). With a 30-month follow-up, the IIEF-5 was consistent in both groups, with no statistical significance between the groups (p=0.492). The main change in penile length during the operation was increased and still positive in the last follow-up in both groups without statistical significance (p=0.255 and p=0.101, respectively).

Conclusion

Partial plaque excision and corporoplasty with both testicular tunica vaginalis or bovine pericardium grafts are equally effective in treating males with clinically significant PD.

Bibliometric analysis of most cited Peyronie's disease and its management publications

Introduction

Peyronie's disease (PD) is a common urologic illness, motivating numerous scientific investigations and publications. Scientific publications have more authors each year. A bibliometric review of the PD literature might help urologists and sexual medicine professionals comprehend publication tendencies in this subject. The current study was aimed at presenting a bibliometric analysis of PD, which is one of the important and trending subjects of andrology.

Methods

On January 5, 2023, Web of Science scanned documents with the terms Peyronie's disease" "Peyronie's disease treatment", "Peyronie's disease management", "Peyronie's disease surgery" and "Peyronie's disease injection" from 1975 through 2023. Titles, years, authors, citations, citation indices, journal names, authors' countries of origin, article categories, and funding sources were recorded.

Results

"Clinical Efficacy, Safety and Tolerability of Collagenase Clostridium Histolyticum for the Treatment of Peyronie Disease in 2 Large Double-Blind, Randomized, Placebo Controlled Phase 3 Studies" has the most citations and citation index. Most of the T100 articles were published in 2020, primarily in the Journal of Urology. These articles mainly focused on treatment, especially surgeries. All of these articles were in English, and the vast majority of them were by authors from the US who were most frequently collaborated with by other authors.

Conclusion

This research analyzed the top 100 PD studies. This research focused on pathophysiology, innovative surgical procedures, and new approaches of PD. It also recommended bigger databases and more financing for research.

Current trends in non-surgical management of Peyronie's disease-A narrative review

Peyronie's disease (PD) is a connective tissue disorder affecting the tunica albuginea. It can cause pain and penile deformation, and its prevalence increases with age. Although surgery is the gold standard for the chronic phase of the disease, there are several conservative treatment methods available, and the optimal management of the acute phase of the disease remains a matter of debate. In this article, we aim to summarize the recent trends in research on the subject of non-surgical treatment of PD. The search was performed in PubMed, Scopus, and Web of Science databases and included studies in English published between 2012 and 2022 investigating the clinical outcomes of non-surgical PD management in humans. We have identified 20 distinct conservative treatment strategies. Among the oral therapeutics, only the use of phosphodiesterase type 5 inhibitors is currently recommended for clinical use in patients with concomitant erectile dysfunction. The use of collagenase from Clostridium histolyticum is supported by the best quality evidence in terms of intralesional injections for patients suffering from significant penile curvature; however, interferon alpha-2b can also be an option in such patients. Among other non-invasive methods, extracorporeal shockwaves can be useful for pain reduction, and penile traction therapy can lead to a reduction in penile curvature and plaque size. Despite a wide range of non-surgical methods available for PD treatment, the majority are not supported by sufficient scientific evidence, and the treatment efficacy is underwhelming. Further research on the subject of non-surgical management of PD is highly warranted.

Inflatable penile prosthesis placement in Peyronie's disease: a review of surgical considerations, approaches, and maneuvers

Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea that results in penile deformity and/or curvature. Patients usually present complaining of penile pain, shortening and deformity resulting in dissatisfaction with intercourse. Many patients with PD will present with concomitant erectile dysfunction (ED). This disease is a significant concern for patients as it impacts both sexual function and overall quality of life. While there are several interventions available for PD treatment, inflatable penile prosthesis (IPP) implantation is considered the gold standard approach for those with moderate to severe concomitant ED, refractory to medical therapy. The goal of treatment is to give a man a functionally straight erection. Placement of an IPP alone may achieve this. However, when curvature still exists, several adjunct procedures may be performed to include manual modeling, plication, plaque incision or excision and grafting. Additionally, advanced lengthening procedures may also be used. In this paper we will present a comprehensive review of the adjuvant straightening techniques that can be used during IPP placement in men with PD and refractory ED when curvature still exists. Patient selection is a key predictor of implant success, as is preoperative and postoperative management to optimize overall patient care and satisfaction. These topics along with the different surgical approaches to IPP insertion for PD will also be discussed, including the benefits and shortcomings of each. A flowchart to aid surgeons in their intraoperative decision making based on curvature characteristics and specific patient concerns is presented.

[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.

Thematic analysis of the psycho-sexual symptoms in patients with Peyronie's disease present on online forums

Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea that may result in penile deformity, pain, a palpable plaque, and erectile dysfunction. In order to understand the psycho-sexual impacts of PD on patients and their partners, we selected three online forums containing the largest number of threads on PD. Threads focusing on the psycho-sexual impacts posted from January 1, 2011 to January 1, 2021 were compiled, and thematic analysis was performed on Dedoose. There were 277 unique posters, including 225 patients and 52 partners. Eighty-four categories and five themes were developed including information and social support, physical symptoms, psycho-sexual symptoms, treatment and effect, and impacts on partners and relationship. Emotional distress including depressed mood (n = 75, 33.3%) and feelings of isolation (n = 41, 18.2%) was prevalent. Partners developed sexual dysfunction including sexual dissatisfaction (n = 11, 21.2%) and dyspareunia (n = 4, 7.7%). Relationships experienced disruption (n = 14, 5.1%) or termination (n = 10, 3.6%). Posters received psychological treatment including psychotherapy (n = 20, 8.9%) and antidepressants (n = 17, 7.6%). Of these, 12 reported improvement and 11 stated no improvement. On these forums, psychological burden affecting individuals with PD and their partners is reported. Few seek help from a psychologist or therapist, and psychological distress may persist even after successful PD treatment. Further research is needed to identify strategies for effective psychological management.

Penile surgery for patients with Peyronie's disease initially treated with collagenase clostridium histolyticum or surgery: a claims database analysis

Collagenase clostridium histolyticum (CCH) is an injectable therapy targeting collagen present in penile plaques in Peyronie's disease (PD). Data comparing CCH to penile surgery are limited, and long-term therapeutic outcomes are unknown. This retrospective analysis used a US claims database (January 2014-June 2017) to determine the percentage of men with subsequent penile surgery among those who initially received CCH (n = 1227) or surgery (index treatment; n = 620) for PD. Eligible patients were aged ≥18 years with continuous enrollment ≥6 months before and ≥12 months after index treatment date. During 12 months of post-index treatment follow-up, fewer patients with PD initially treated with CCH (4.6% [56/1227]) had subsequent penile surgery versus those initially treated with penile surgery (10.3% [64/620]; p < 0.0001). Mean ± SD time to first subsequent surgery after initial PD treatment was longer in the CCH versus surgery cohort (7.7 ± 3.0 vs 1.7 ± 3.2 months). The likelihood of subsequent surgery varied by initial surgery type: 18.2% after plaque incision or excision with grafting; 11.6% after penile implant; and 8.2% after tunical plication. Patients with PD who received CCH first were less likely to undergo subsequent surgery compared with those who received surgery first within a 12-month post-treatment follow-up.

A Randomized, Single-Blinded Clinical Trial Evaluating the Effect of Extracorporeal Shockwave Treatment (ESWT) as Add-On Therapy to Vacuum Erectile Device on Peyronie's Disease

Purpose

The aim of this study was to investigate whether ESWT with a higher energy as an add-on therapy to vacuum-pump followed by manipulation exercises could reduce the penile curvature, pain and improve IIEF-5 score.

Materials and Methods

Men aged >18 and <80 years and diagnosed with PD in stable phase with no history of penile surgery or previous ESWT treatment were eligible to participate. They were randomised to either active ESWT (n = 16) or sham ESWT (n = 16). Both groups were treated once a week for five weeks. Each treatment session consisted of 2000 shockwaves at 0.5mJ/mm². All patients in both groups used a vacuum pump followed by manipulation exercises.

Results

Thirty men completed the study protocol. Mean age in the treatment group was 61.7 (SD 8.3) and 63 (SD 7.35) in the control group. After six months, mean change in penile curvature was −12.8 (SD 13) degrees in the treatment group and −6.6 (SD 8.9) in the control group (p = 0.204). Mean IIEF-5 score decreased by 0.17 (SD 3) in the treatment group and 3.06 (SD 5.5) in the control group (p = 0.086) at six-month follow-up. Pain was assessed using both VAS and PDQ and demonstrated no difference between the groups after six months (p = 0.648).

Conclusion

In the treatment group, we observed a greater but non-significant change in penile curvature and no adverse effects.

Molecular Mechanisms and Current Pharmacotherapy of Peyronie's Disease: A Review

Peyronie’s disease (PD) is a localized fibrotic lesion of the penis that has adverse effects on men’s health. In this review, we summarized the molecular mechanisms and pharmacotherapies of PD. A literature search was conducted using PubMed and Cochrane Library during 2001–2020. Although no oral or topical medication demonstrated efficacy in monotherapy of PD, several intralesional medications have yielded promising results. Currently, the effective strategy in management of PD should be combined modality therapy, including but not limited to pharmacotherapy, mechanical therapy, and psychotherapy. Meanwhile, basic research is still necessary to facilitate the development of novel and more reliable treatments. In future, more attention should be given simultaneously to epigenetic changes, inflammatory cytokines, the abnormal wound-healing process, and profibrotic and anti-fibrotic factors to provide more options for this refractory disease.

Fibroproliferative disorders and diabetes: Understanding the pathophysiologic relationship between Peyronie's disease, Dupuytren disease and diabetes

Introduction

Fibrosis is characterized by dysregulation and accumulation of extracellular matrix. Peyronie's disease and Dupuytren disease are fibroproliferative disorders of the tunica albuginea of the penis and fascia of the hand, respectively. Chronic hyperglycaemia due to diabetes mellitus can also lead to tissue injury and fibrosis. A meta-analysis has shown a relationship between Dupuytren disease and diabetes (overall odds ratio, 3.1; 95% confidence interval, 2.7-3.5). This review explores commonalities in the pathogenesis of Peyronie's disease, Dupuytren disease and diabetes.

Methods

A search of the PubMed database was conducted using the search terms "diabetes" AND "Peyronie's disease"; and "diabetes" AND "Dupuytren."

Results

Genome-wide association and gene expression studies conducted with tissue from people with Peyronie's disease or Dupuytren disease identified signalling pathways associated with wingless-type mammary-tumour virus integration site signalling, extracellular matrix modulation and inflammation. Biochemical studies confirmed the importance of these pathways in the pathogenesis of fibrosis with Peyronie's disease and Dupuytren disease. Dysregulation of matrix metalloproteinase activity associated with extracellular matrix breakdown was implicated in fibroproliferative complications of diabetes and in the aetiology of Peyronie's disease and Dupuytren disease. A notable percentage of people with diabetes have comorbid Peyronie's disease and/or Dupuytren disease.

Conclusions

Studies have not been performed to identify fibroproliferative pathways that all 3 conditions might have in common, but data suggest that common pathways are involved in the fibroproliferative processes of Peyronie's disease, Dupuytren disease, and diabetes.

Efficacy of H-shaped incision with bovine pericardial graft in Peyronie's disease: a 1-year follow-up using penile Doppler ultrasonography

We present our experience with the use of an H-shaped incision and a bovine pericardial graft in patients with Peyronie's disease (PD). In this retrospective study, 21 male patients with PD who underwent an H-shaped incision and received a bovine pericardial graft were included and followed for at least 1 year. The degree of penile curvature in all subjects was >60°. Patients had no erectile dysfunction prior to surgery. Outcomes assessed were resistive index (RI) in penile Doppler ultrasonography, improvements in curvature, erection hardness score, and postoperative patient satisfaction. The median age of the 21 patients was 58 (55, 63) years and the median duration of PD was 7 (6, 12) months. As the efficacy variable, there was no statistically significant change in the RI of the corpus cavernosum at 1 year post-surgery. The degree of penile curvature in the erectile state was remarkably decreased from 70 (60, 90) degree to 5 (5, 15) degree (P < 0.001). There was no significant change in the erection hardness score before and after surgery. Patient satisfaction evaluated via a Likert-type scale at 1 year after surgery was 4 (4, 5). In multiple linear regression analysis, patient satisfaction was correlated with the intraoperative defect size created by H-shaped incision (P = 0.009) and inversely related with the residual curvature (P < 0.001). The results from the subjective symptom score and the objective penile Doppler ultrasonography suggest that the H-shaped incision and the subsequent graft with the bovine pericardium is safe and effective in patients with PD. It is necessary to minimize the remnant curvature during graft surgery, because postoperative patient satisfaction was closely correlated with postoperative residual curvature.

Antioxidant Mechanism of Xiaojin Pill () for Treatment of Peyronie's Disease in Rats Based on Matrix Metalloproteinases

OBJECTIVE

To evaluate the effects of Xiaojin Pill () in the treatment of Peyronie's disease (PD) in a rat model.

METHODS

Twenty-four male Sprague-Dawley rats were randomly divided into four groups with 6 in each: sham operation, PD model, vehicle control and Xiaojin Pill groups. The rats in the sham operation group received penile tunica albsginea (TA) injection with 50 μL vehicle, while the rats in the other 3 groups received 50 μL penile TA injection of 50 μg transforming growth factor (TGF)-β1. Forty-two days after the injection, rats in the vehicle control and Xiaojin Pill groups received 0.5 mL water and Xiaojin Pill solution (107 mg/kg of body weight), respectively by gavage for 28 days, while those in the sham operation and PD model groups did not receive any intervention. After intervention, the expressions of matrix metalloproteinase 2/9 (MMP2/9), nitric oxidesynthase (NOS), superoxide dismutase (SOD) and malondialdehyde (MDA) were measured.

RESULTS

Rats in the PD model and vehicle control groups presented obvious fibrosis in corpus cavernosum (CC) and demonstrated a significantly increased expressions of MMP2 and MMP9 in the CC compared with the sham operation group (all P<0.01). In contrast, the expressions of MMP2 and MMP9 in the Xiaojin Pill group were significantly down-regulated (both P<0.01). In addition, the levels of NOS and MDA in CC were significantly increased while the activity of SOD was decreased in the PD model and vehicle control groups compared with the sham operation group (all P<0.01). After Xiaojin Pill treatment, the levels of MDA, NOS and SOD appeared to be corrected (all P<0.01).

CONCLUSIONS

Xiaojin Pill could reduce fibrosis in the CC by decreasing the expressions of MMPs, NOS and MDA, and by increasing the activity of SOD. Therefore, Xiaojin Pill might be a therapeutic option for PD.

Increased Risk of Cancer in Men With Peyronie's Disease: A Cohort Study Using a Large United States Insurance Claims Database

Background

Men with Peyronie’s disease (PD) may have an increased prevalence of certain comorbidities, including malignancy. We sought to examine the clinical relationship between PD and subsequent diagnosis of malignancy.

Methods

Using data from the IBM Health MarketScan claims database from 2007 to 2013, we compared men with PD to a control group of men without PD or erectile dysfunction matched for age and duration of follow-up. We compared incidence of 18 categories of malignancy between both groups using a Cox regression model.

Results

In total, 48,423 men with PD and 484,230 controls were identified. The mean age within both cohorts was 50 ± 9.4 years old, and mean follow-up time was approximately 4.4 ± 2.1 years. After being controlled for age, year of evaluation, obesity, smoking, number of outpatient visits, number of urologist visits, and duration of follow-up, men with PD had an increased risk of all cancers (hazard ratio = 1.10, 95% CI = 1.06–1.14), stomach cancer (1.43, 1.06–1.14), testis cancer (1.39, 1.05–1.84), and melanoma (1.19, 1.02–1.38) when compared with controls. The strengths in using the MarketScan database are the anonymous nature of the data, accessibility, and the power provided by the large number of patient visits recorded. Limitations include a lack of detail in certain facets of patient clinical data, and the lack of long-term follow-up to assess the impact of time on other potentially associated conditions.

Conclusions

This manuscript is the first to our knowledge to describe a relationship between PD and cancer. Men with PD may be at increased risk for certain malignancies compared with age-matched controls. Further investigation is needed to explore the clinical implications of these findings.

Pastuszak AW, Thirumavalavan N, Kohn TP, et al. Increased Cancer Risk in Men With Peyronie’s Disease: A Cohort Study Using a Large US Insurance Claims Database. Sex Med 2019;7:403–408.