Dr. med. Dirk Manski

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Peyronie disease: Diagnostic Workup and Treatment

Review literature: (Gholami et al., 2003) (Hauck et al., 2006) (Tunuguntla, 2001).

Diagnostic Workup for Peyronie Disease

Physical examination:

Location and size of the plaques. Documentation of stretched penile length before invasive therapy. Examination of hands and feet for concurrent fibrotic diseases.

Photo documentation of the deviation

Photo-documentation of the penile deviation is recommended before surgical treatment after self-stimulation or intracavernosal injection of prostaglandin.

Sonography of the Penis

Penile plaques can be seen with ultrasound imaging using a high-resolution linear transducer. The plaques are limited to the tunica albuginea, unlike sarcoma or other malignant penile diseases. Calcifications cause acoustic shadowing.

Duplex (Doppler) Ultrasound Imaging of the Penile Blood Vessels

Vascular testing is indicated for patients with erectile dysfunction and before invasive therapy. Documentation includes penile length, degree of penile deviation, and the vascular parameters during full erection. The most common cause of erectile dysfunction is veno-occlusive dysfunction.

Cavernosography

Cavernosography is seldom indicated in Peyronie disease. Cavernosography can diagnose veno-occlusive dysfunction, localize the venous leakage, and confirm the Doppler ultrasound findings.

Medical Treatment of Peyronie Disease

The early inflammatory stage of the disease is treated with anti-inflammatory drugs and phosphodiesterase inhibitors (Hauck et al., 2006). The EAU guideline does not recommend medical treatment with para-aminobenzoic acid, acetyl-L-carnitine, vitamin E, tamoxifen, or colchicine due to their low effectiveness and relevant side effects.

Phosphodiesterase 5 inhibitors:

PDE5 inhibitors lead to improved penile blood flow, an increase in cGMP and NO in the corpus cavernosum, and an additional antifibrotic effect has also been demonstrated in vitro. In retrospective studies, the long-term administration of PDE5 inhibitors in the early stages of IPP has shown an improvement in pain and deviation, while also effectively treating erectile dysfunction. Dosage: Tadalafil 5 mg or Sildenafil 50 mg once daily.

Non-steroidal anti-inflammatory drugs (NSAIDs):

NSAIDs are an option for relieving painful erections in the early stages of the disease. Dosage: Ibuprofen 600 mg or diclofenac 75 mg if needed (before intercourse).

Potassium Aminobenzoate (Potaba)

Potassium Aminobenzoate (Potaba) is an antifibrotic drug. Potaba reduced the plaque size in a randomized study and prevented the worsening of the penile deviation. An existing deviation could not be improved, as the effect on pain was insignificant (Weidner et al., 2005). The dosage of Potaba is 4 × 3 g p.o. Potaba is approved in Germany for treating the active phase of IPP, but the AUA and EAU guidelines advise against its use.

Drugs without Evidence of Efficacy in Randomized Trials

Intralesional Injections for Peyronie disease

Intralesional injections are used to increase the local drug concentration in the plaques and to avoid systemic side effects.

Collagenase

The repeated (8x) intralesional injections of collagenase clostridium histolyticum (Xiapex) combined with the repeated use of a vacuum pump and mechanical stretching improved penile deviation by 17 degrees. Due to its effectiveness in controlled studies, the drug received FDA approval (Gelbard et al., 2013). The recommended xiapex dose is 0.58 mg per performed injection into a peyronie plaque. The drug costs amount to 8000 euros. Even with a reduced dosage of the costly drug (three injections at 4-week intervals), improvement in deviation of 54 degrees (30–90) to 37 degrees (12–75) was achieved (Abdel et al., 2017a). Side effects of collagenase therapy include hematoma, pain at the injection site, and increased risk of rupture of the tunica albuginea (1%). The drug is no longer commercially available on the European market (as of 2020).

Verapamil Infiltrations

Verapamil has an inhibitory effect on fibroblasts and increases the production of collagenases. The efficacy of verapamil on Peyronie disease is controversial. Several uncontrolled and randomized studies showed the effectiveness of verapamil infiltrations. Two other randomized studies found no efficiency.

Dosage of verapamil infiltrations: local infiltration of 10 mg verapamil diluted in 10 ml every two weeks, to a total of 12 injections.

Interferon

Interferon inhibits fibroblasts and increases the production of collagenases. In particular, high-dose interferon treatment (5-10 MU interferon-α 2b) demonstrated in several controlled trials effectiveness in pain reduction, improvement of sexual function, and penile deviation.

Cortisone

Despite its relatively frequent use, cortisone injections are probably not effective (one controlled study without effectiveness).

Further Nonsurgical Treatment Alternatives for Peyronie Disease

Electromotive Treatment (Iontopheresis)

Electromotive treatment uses the help of a weak electric current to bring ionized substances in high concentrations to penile plaques. Systemic side effects can be avoided. Agents used are verapamil, dexamethasone and lidocaine. Controlled studies are missing, and guidelines do not recommend electromotive treatment.

Extracorporeal Shock Wave Therapy (ESWT)

Several sessions of ESWT with, e.g., 2000 shock waves on the plaques of Peyronie disease improve pain. Some of the plaques are reduced in size, and an improvement in the deviation is not very likely (Hauck et al., 2006). Recent studies showed improvement in erectile function with repeated shock wave therapy (Fojecki et al., 2017).

Mechanical stretching of the penis:

The repeated use of special devices can improve penile length and deviation. The device must be used daily for several hours and is a therapeutic option for motivated patients (Ziegelmann u.a., 2019).

Radiation Therapy:

Radiation therapy is an option in the early inflammatory phase of Peyronie disease, but only retrospective trials with low quality are available. Irradiation is effective against painful erections, but the deviation improvement is uncertain (Seegenschmiedt et al., 2015).

Surgical Treatment of Peyronie Disease

Indications for Surgery due to Peyronie disease

After evaluation of conservative treatment alternatives and only for patients with stable stage of disease (at least one year of consistent deviation), surgery is a treatment option depending on the extent of the deviation and erectile function.

Nesbit Operation for Peyronie disease

During Nesbit operation, an elliptical excision of the tunica albuginea on the convex side and closure enables enables straightening the penile deviation (Nesbit, 1965). A modified technique recommends a longitudinal incision of the tunica albuginea and horizontal closure (Yachia, 1990).

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Advantage of the Nesbit technique: no mechanical weakening of the penile shaft by grafting. Disadvantage of the Nesbit technique: substantial deviations can only be straightened with a significant loss in penile length. For technique and complications of the Nesbit procedure, please refer to Section Urologic Surgery.

Plication technique by Essed and Schroeder

The excision of the tunica albuginea (Nesbit procedure) is omitted. Reduction stitches with nonabsorbable sutures shorten the tunica albuginea on the convex side and straighten the penile deviation. For technique and complications of the Nesbit procedure, please refer to Section Urologic Surgery.

Plaque Incision and Grafting

After the incision/excision of the penile plaque on the concave side, the penis can be straightened. The corporatomy creates a defect in the corpus cavernous. This defect is covered with endogenous or exogenous materials (skin, vein, allogeneic material). Penile straightening is possible without shortening of the penis. For technique and complications, please refer to Section Urologic Surgery.

Implantation of a Penile Prosthesis

In patients with Peyronie disease with severe erectile dysfunction, despite intracavernosal injections, erectile function after plaque incision and grafting cannot be expected. These patients should be offered a penile prosthesis as a surgical treatment option.





Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

References

A. Nehra et al. “AUA Guideline: Peyronie’s Disease,” 2015. [Online]. Available: https://www.auanet.org/guidelines-and-quality/guidelines/peyronies-disease-guideline.

EAU-Guidelines: Sexual and Reproductive Health

Gholami u.a. 2003 GHOLAMI, S. S. ; GONZALEZ-CADAVID, N. F. ; LIN, C. S. ; RAJFER, J. ; LUE, T. F.: Peyronie’s disease: a review.
In: J Urol
169 (2003), Nr. 4, S. 1234–41

Hauck, E. W. u. a. (2006). A critical analysis of nonsurgical treatment of Peyronie’s disease. In: Eur Urol 49, S. 987–997.


Nesbit 1965 NESBIT, R. M.: Congenital Curvature of the Phallus: Report of Three Cases with Description of Corrective Operation.
In: J Urol
93 (1965), S. 230–2

Nesbit 1965 NESBIT, R. M.: Congenital Curvature of the Phallus: Report of Three Cases with Description of Corrective Operation.
In: J Urol
93 (1965), S. 230–2

Tunuguntla 2001 TUNUGUNTLA, H. S.: Management of Peyronie’s disease-a review.
In: World J Urol
19 (2001), Nr. 4, S. 244–50

Yachia 1990 YACHIA, D.: Modified corporoplasty for the treatment of penile curvature.
In: J Urol
143 (1990), Nr. 1, S. 80–2


Weidner, W. u. a. (2005). Potassium paraaminobenzoate (POTABA) in the treatment of Peyronie’s disease: a prospective, placebo-controlled, randomized study. In: Eur Urol 47, 530–5; discussion 535–6.




  Deutsche Version: Therapie der Induratio penis plastica (Morbus Peyronie)