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Peyronie’s Disease (PD) is an acquired wound healing disorder affecting the tunica albuginea of the corpus cavernosum. There are numerous treatment options, both medical and surgical.  Medical therapies are often used however there is a paucity of well designed randomized clinical trials (RCT) that show meaningful benefit with any of these medications.   The goal of medical therapy is at a minimum to stabilize the scar formation during the acute phase, as well as hopefully improve the deformity, and reduce pain.  It is an appropriate first-line option for men during the acute phase of the disease process.  Surgery is contraindicated until about one year after onset of PD.  

Injection therapy using collagenase clostridium histolyticum (CCH) has been widely adopted since its FDA approval in 2013.  The collagenase is produced by the bacteria Clostridium Histolyticum and works by degrading both types I and II collagen within the PD plaque1. Two large RCT, IMPRESS 1 and 2, compare CCH to placebo showing a mean 17 degree curvature improvement in the CCH group compared to 9.3 degree improvement in the placebo group2,3.  CCH has not been shown to improve erectile function, indentation or provide length restoration.  The authors believe that men with extended crescent-like curves, curvature over 90 degrees, painful plaques, extensive plaque calcification, or hourglass deformities are poor candidates for CCH.  A significant limitation to its use is cost, with one cost analysis showing patients on average spending $25,000 on CCH treatment4.  Although a recent study has shown similar outcomes using a modified protocol requiring fewer injections, CCH remains an expensive medication.

Surgery remains the gold standard for PD treatment in the stable phase.  The goal is to provide the patient with a functionally straight penis, which has been defined as 20 degrees or less5.  There are a variety of surgical procedures that have been described and an algorithm was developed to aid in determining the ideal procedure for each individual patient6,7.  Men who have adequate rigidity for intercourse with or without the use of pharmacotherapy are good candidates for either tunica albuginea plication (TAP) or plaque excision and grafting (PEG).  TAP is ideal for men with less severe curvatures (<60-70 degrees), no hourglass or hinge, and adequate penile length.  PEG is more ideal for men with curves of >60-70 degrees, the presence of hinge or hourglass deformity, extensive plaque calcification, and strong preoperative erections.  Placement of a penile prosthesis with straightening maneuvers is indicated in PD patients with erectile dysfunction not responsive to oral pharmacotherapy6,7.  The most common adverse effect following surgery is perceived loss of length. Length restoration procedures have recently been developed to address this with promising results reported in small series. 8,9

It is the authors' opinion that the non-surgical therapy most likely to provide meaningful results is combination therapy utilizing oral, intralesional, and external traction therapy. Surgery remains the gold standard for definitive treatment. 

Written by: Edward Capoccia, MD, Rush Urology

References 
  1. Watt AJ, Hentz VR. Collagenase clostridium histolyticum: a novel nonoperative treatment for Dupuytren’s disease. Int J Clin Rhematol. 2011;6:123-133.
  2. Gelbard M, Goldstein I, Hellstrom WJ, et al. 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. J Urol. 2013;190:199-207.
  3. Lipshultz L, Goldstein I, Seftel A, et al. Clinical efficacy of collagenase clostridium histolyticum in the treatment of Peyronie’s disease by subgroups: results from two large, double-blind, randomized, placebo-controlled, phase 3 studies. BJU Int. 2015;116:650-656.
  4. Cordon, B. H., Hofer, M. D., Hutchinson, R. C., Broderick, G. A., Lotan, Y., & Morey, A. F. (2017). Superior Cost Effectiveness of Penile Plication vs Intralesional Collagenase Injection for Treatment of Peyronie's Disease Deformities. Urology Practice4(2), 118-125. 
  5. Martinez-Salamanca JI, Equi A, Moncada I, et al. Acute phase Peyronie’s disease management with traction device: a nonrandomized prospective controlled trial with ultrasound correlation. J Sex Med. 2014;11:506-515.
  6. Levine LA, Lenting EL. A surgical algorithm for the treatment of Peyronie’s disease. J Urol. 1997;158(6):2149-52.
  7. Levine, L. A., and R. J. Dimitriou. A surgical algorithm for penile prosthesis placement in men with erectile failure and Peyronie's disease. International journal of impotence research 12.3 (2000): 147-151.
  8. Wilson SK, Delk JR. A new treatment for Peyronie's disease: modeling the penis over an inflatable penile prosthesis. J Urol 1994; 152: 1121.
  9. Morey AF. Re: Penile Lengthening and Widening without Grafting According to a Modified 'Sliding' Technique. J Urol. 2016;195(6):1822-3.
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