Link: LINK
The non-surgical management of Peyronie’s disease has
significantly advanced, but despite multiple randomized
trials and uncontrolled case series, one treatment alone
has not been found to be definitively superior. Proposed
oral therapy has included pentoxifylline, colchicine, and
potassium para-aminobenzoate (12-14). In cases where
the Peyronie’s lesion is readily accessible, intralesional
administration of Verapamil, Interferon, and Collagenase
have all been tried with some success (15-17). In
uncontrolled studies, traction devices and vacuum devices
have been shown to result in some benefit to curvature
(18,19).
The mechanisms of Peyronie’s plaque formation have not
been fully defined, but likely begins with an inflammatory
process, possibly from trauma, which then leads to
fibrosis, decreased elasticity and excess collagen deposition
(20,21). Oral therapies, such as pentoxifylline may act on
inflammation and early fibrosis. Indeed, pentoxifylline has
been shown to inhibit fibrosis induced by Transforming
Growth Factor (TGF) Beta-1 (22).
Intralesional therapies, such as interferon alpha-2b, may
also limit inflammation and early fibrosis by decreasing
fibroblast proliferation, extracellular matrix production,
and collagen production from fibroblasts (17). Clostridial
collagenase is a purified bacterial enzyme that selectively
breaks up collagen, and thus may help further with late
fibrotic scars, rich in collagen (16,23).
However, when working with intralesional therapies,
it is important to be able to target the lesion. Thus, while
plaques on the dorsum of the penis are readily accessible,
patients with ventral plaques, intracorporal or septal fibrosis
(Figure 4) and large calcifications may be less treatable
with this method. Indeed, in a review of 891 men receiving
penile ultrasonography for Peyronie’s disease, Chung et al.
found that 43% of patients had septal fibrosis (24).
The “incurable” component of the Peyronie’s disease
is the late dense fibrosis and “loss of elasticity” that is
refractory to medical treatments including the most
powerful therapy, the intralesional injection of collagenase.
Dissolving or softening the plaque alone does not
straighten the penis fully, as evidenced by recent clinical
trials (8,23). The best results are in patients who have had
a “modeling” procedure where the physician forcefully
stretches the softened plaque after several injections of
collagenase. Penile traction and vacuum erection devices
help address the issue of loss in elasticity. These therapies
will mechanically stretch the tunica to help straighten the
penis. Levine’s group has shown previously that therapy
combining oral or intralesional therapy with penile traction
provides both length and reduction in curvature (10).
Given the multiple components of Peyronie’s disease
(inflammation, fibrosis, and loss of elasticity), we typically
recommend combination therapy for patients with
moderate-to-severe curvatures or shortening, utilizing
pentoxifylline and a vacuum device (Table 1). With vacuum
therapy alone, inflammation from trauma would continue,
and fibrosis would likely recur. In the case of more severe
curvatures, pentoxifylline alone is unlikely to overcome the
overall loss in elasticity, and thus minimal benefit will be
seen with regards to straightening.
Decisions to pursue surgery should be patient centered.
Indications to pursue surgical intervention include disease
refractory to medical therapy alone, moderate-to-severe
curvature. Curvature alone may typically be managed
successfully with plication alone (25). Patients with hourglass
deformities or large areas of calcification may benefit
from tunical excision and grafting, but these patients
must be counseled on the high risk of subsequent ED.
Alternatively, a subtunical excision of ossified portion
of plaque and plication may achieve the same goal with
minimal risk of penile numbness and ED (4).
1263-PB2-R1.pdf (729 KB)