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AUA 2023: Spotlight on Peyronie’s Disease

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What’s up with the bent carrot ads on TV, doc? Peyronie’s Disease (PyD) is a devastating disorder of the penis in which sufferers sustain acquired penile deformities resulting in curvature, length loss, instability and other shape changes rendering penetrative intercourse difficult or impossible.  Most physicians never receive formal training in evaluating and treating PyD despite the catastrophic effect it has on a man’s mental and physical health.  A study coauthored by researchers from Karolinska Institute and UCLA in the Journal of Urology in 2021 show a nearly twofold higher risk of depression in men with Peyronie’s Disease.  

On Sunday, April 30, a plenary session at 11:10 AM in Hall B1, moderated by Helen Bernie, DO, will showcase some of the most respected thought leaders in the field as they debate the multiple treatment options available to men suffering with Peyronie’s.

What should the audience expect from this moderated debate on treatment options for PyD?

The established patient scenario presents a man with a 60-degree dorsal curvature with erection.  His erectile strength is mildly impaired, and he’s very concerned with his loss of penile length.  

Options for Peyronie’s Disease therapy include observation, stretching and modeling devices, oral medication, intralesional therapy and multiple surgical procedures.  All treatment modalities carry risks and provide different levels of success.  Men need to know that PyD rarely resolves spontaneously and therefore observation will leave a man with his current or worsening impairment.

There are no FDA approved oral medications to treat PyD and current AUA guidelines give a poor grade to any off-label medications—from Phosphodiesterase inhibitors, colchicine, tamoxifen, pentoxyphyline to potaba, many pills have tried and failed to effect a positive change in penile deformity.

One of the greatest advances in treatment for PyD is intralesional injection of collagenase clostridium histolyticum (CCH), a biologically derived enzyme the FDA approved for treating Dupuytren’s Contracture, Peyronie’s Disease and recently cellulite.  Clinicians inject the drug in 8 installments over a spaced and scheduled course of a little over 4 months.  It is an effective, albeit expensive, drug with an excellent safety profile but it is by no means a cure for the majority of men.  Clinical trials suggest roughly a 35% improvement in curvature and a significant improvement in self-reported bother.  That leaves a lot of men with residual curvature, and Xiaflex carries the small risk of corporal rupture.

Any disease state with multiple treatment options sets the stage for a robust debate.  Amy Pearlman, MD, will present a nonsurgical argument to implement penile traction devices.  This approach has the advantage of some curvature reduction and length improvement but would be unlikely to offer the same degree of correction as the other approaches.  I will discuss CCH therapy.  CCH offers the only FDA approved non-surgical treatment pathway but, as I discussed earlier, has limitations and carries a hefty price tag.

Dr. Al Morey, UT Southwestern, will discuss his less invasive approach of surgical plication which can provide excellent curvature improvement but leaves the plaque in situ and can cause additional penile shortening.  Dr. Rafael Carrion, University of South Florida, will try to persuade the audience that surgical plaque excision with penile grafting (PEG) will give the patient the best outcome.  While PEG may offer definitive plaque and curvature management, the surgery has the highest risk profile of sensory loss and worsening erectile function.    Dr. Martin Gross from Dartmouth Hitchcock discusses the advantages of treating the man’s erectile dysfunction and PyD with penile implant placement with adjunct procedures.  While offering a one surgery addressing 2 disease states, penile prosthesis has the highest risk of infection and mechanical failure of any of the surgical treatments for PyD.

Whatever the outcome of the debate, the audience is sure to take away a better understanding of an underreported male health problem with devastating physical and mental side effects.

Dr. Mills has no conflicts of interest to report.

Image by Visual Generation / Shutterstock

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