Oral agents have long been an appealing option for PD management, especially given ease of administration and theoretic ability to provide balanced tissue penetration in the tunica albuginia. Numerous oral agents have been trialed in PD patients with variable results including the following: Potoba, Vitamin E, Tamoxifen, Procarbazine, Colchicine, Carnitine, Pentoxifylline, Omega-3 fatty acids, Coenzyme Q10, and Phosphodiesterase type 5 inhibitiors. Although a number of well designed, prospective studies evaluating oral agents have been completed, their significance is limited by small sample size compromising their statistical power. Results vary widely and reproducible objective benefit has not yet been strongly established for any single oral agent. Based on the best available evidence, we do not currently recommend routine use of any oral agent for the treatment of Peyronie’s disease.
Although there is no single non-surgical treatment modality that provides convincing, reproducible, and durable benefit in patients with PD; the body of literature does suggest that a variety of therapies can reduce deformity, improve sexual function, reduce pain, and stabilize the disease process. Pharmacologic agents have been most effective when adequate concentrations are able to penetrate the tunica albuginea, either by iontophoresis (verapamil) or via intralesional injection (verapamil, nicardipine, interferon alpha, Collagenase clostridium histolyticum). To date, pharmacologic agents have been most effective when adequate concentrations are able to penetrate the tunica albuginea, either by iontophoresis or via injection. Calcium channel blockers, administered via intralesional injections and transdermal ionotophoresis administration, have gained support in multiple small trials. When used as injection therapy for Peyronie’s disease, we feel that the body of evidence does support the use of verapamil, especially in patients with plaque-associated pain.
Most recently, intralesional Collagenase clostridium histolyticum became the first pharmacologic agent to obtain Food and Drug Administration approval for use in Peyronie’s disease and is supported by promising data from a large-scale, phase III randomized controlled trial. We currently offer intralesional Collagenase clostridium histolyticum to Peyronie’s disease patients in the acute or stable phase of disease so long as they do not have significant plaque-related pain. In those with pain, intralesional verapamil is preferred. Patients with severe curvature (i.e. >90⁰), ventral curvature, or extensive plaque calcification are not considered candidates for Collagenase clostridium histolyticum at this time.
Although oral and topical therapies have not had significant benefit as monotherapy for Peyronie’s disease to date, some may prove to have a synergistic role when used in combination with mechanical traction and/or intralesional therapies. However, the synergistic effects of various modalities will not be clearly defined without larger trials.
Decades of Peyronie’s disease research have helped to uncover some of the key tissue and inflammatory factors involved in the development of Peyronie’s disease. However, a definitive etiology or mechanism for this disorder is not completely understood. Key goals in Peyronie’s disease management include improving our ability to identify patients at risk of developing Peyronie’s disease, finding ways to intervene in the early stages of the disease to slow or prevent progression, and ultimately develop effective and minimally invasive measures to reverse penile plaque formation without compromising erectile and sexual function. The role of transforming growth factor-beta 1, oxygen free radicals, nitric oxide, myofibroblasts, and genetic factors contributing to fibrosis are key targets for ongoing research and future therapies.
Benjamin A Sherer MD, Karl Godlewski, Laurence A Levine MD
Rush University Medical Center, Chicago IL.