Monday, 7 November 2016

Medical treatment for Peyronie's Disease. What does actually work?

Medical therapy in Peyronie's Disease can play a role both in the acute and chronic phase of the condition.

In the acute phase, the aim of medical therapy is to promote a quicker resolution of pain and inflammation in order to improve patient's quality of life and minimize the damage in terms of deformity and penile shortening produced by the plaque. In other words, during this phase, medical treatment should be offered to limit the potential progression of Peyronie's Disease so that surgery may not be needed, and if required, less invasive forms of surgical procedures can be offered to correct the deformity.

In the chronic phase of Peyronie's Disease, once the inflammatory process has settled and the curvature has stabilized, the aim of medical therapy is to reduce the degree of deformity and/or improve the quality of the erections in patients with a degree of erectile dysfunction.

It is paramount to keep in mind that around 9% of patients with Peyronie's Disease will notice a progressive reduction in the severity of their penile deformity, and that as a general role, any form of treatment is indicated only when the deformity and/or the worsening of the quality of the erections renders penetrative sexual intercourse uncomfortable or impossible.

Unfortunately none of the conservative treatment options will work for every patient and therefore a  multi-modal approach should be always advised and should be tailored to the unique indiidual profile of each patient.

With the exception of injection of Collagenase Clostridium Histolyticum, patients need to be aware that benefits of medical treatment during the chronic phase of Peyronie's Disease are minimal.

Oral Medication for Peyronie’s Disease

Although a large number of oral medications and supplements have been proposed over the years for the treatment of Peyronie’s Disease, none of these have shown a significant therapeutic benefit when compared with placebo.

The most common oral treatments for Peyronie's Disease are reported:

Vitamin E and propionyl-L-carnitine in isolation and combination (Supplement)

Vitamin E and propionyl-L-carnitine in isolation and combination have proven to be completely ineffective for the treatment of Peyronie's Disease.

Colchicine (Prescription drug)

Colchicine is an anti-gout agent that prevents the deposition of scar tissue ad therefore has been prescribed to patients affected by Peyronie's Disease with the aim to minimize scar formation. However, there is no clinical evidence that the administration of Colchicine has any role in limiting the progression of Peyronie's Disease.

Potassium aminobenzoate – POTABA (Prescription drug)

Although POTABA may play a minor role in inhibiting the progression of the plaques, it is also associated with severe gastrointestinal side effects and therefore it is not recommended.

Tamoxifen citrate (Prescription drug)

This is another compound that may potentially inhibit scar formation but there is no clinical evidence of any benefit in patients with Peyronie’s Disease.

Pentoxifylline (Prescription drug)

Pentoxifylline administration may result in a moderate reduction in plaque size and in penile curvature. The cost of the medication is relatively low and although there are some potential side effects, it is one of the treatments that patients can try during the acute phase of Peyronie’s Disease with the aim to reduce progression.

Coenzyme Q10 and Acetyl-L-carnitine (Supplement)

Coenzyme Q10 and Acetyl-L-carnitine administration during the acute phase of Peyronie's Disease may inhibit disease progression. However further studies are required to see whether these two supplements are really effective in this group of patients.


Phosphodiesterase type 5 inhibitors


Phosphodiesterase type 5 inhibitors (PDE5i) such as Viagra, Cialis and Levitra may also play a role both in the acute and chronic phase of Peyronie's Disease. During the acute phase these medications, by increasing the strength of erections, provide a good stretch to the plaque and may play a role in limiting the potential progression of the disease and minimizing the degree of penile shortening. Furthermore, PDE5i may play locally a role at the level of the plaque by inhibiting the deposition of scar tissue. In the chronic phase of Peyronie's Disease instead, PDE5i may be useful in patients with a degree of erectile dysfunction in order to guarantee the rigidity necessary to engage in penetrative sexual intercourse.

Injection Therapy for Peyronie’s Disease

Intralesional injections of a variety of medications have been proposed in patients with Peyronie’s disease. Over the years, the most commonly injected medication has been Verapamil but there is no evidence of any significant benefit in patients with Peyronie's Disease and therefore this practice should be discouraged.

Initial medical trials of intralesional injections of Collagenase Clostridium Histolyticum (Xiapex in Europe, Xiaflex in the USA) have shown promising results and it is currently the only FDA (the government body responsible for approving drugs in the US) approved medical treatment for Peyronie’s disease.

Xiaflex injections are already prescribed to treat Dupuytren’s contracture of the palmar fascia, as this drug works by breaking down the collagen present in the scar tissue of the plaque.

Currently injections of Xiapex are indicated only for patients with dorsal and dorsolateral curvatures. Xiapex injections in ventral plaques are not recommended in order to avoid potential urethral injury. Injections should also not be offered to patients with large calcified plaques due to the risk of rupture of the needle in the hardened plaque.  

Patients need to be counselled that administration of Xiapex injections may produce a reduction of the curvature of around 20-30% but not a complete correction of the deformity. This degree of correction may not be particularly useful in patients with severe curvatures, as a patient with 90 degrees of curvature may expect to get down to around 60 degrees at the end of the cycle of injections, but may  allow patients with a moderate curvature to avoid surgery.

Extracorporeal shock wave treatment (ESWT) for Peyronie’s Disease

There is no evidence that ESWT is beneficial in reducing the degree of curvature in patients with Peyronie's Disease although there is some evidence that it may reduce pain at the level of the plaque during the active phase of the disease. Therefore, ESWT should not be considered an effective treatment option for Peyronie’s Disease.

Traction and vacuum devices for Peyronie’s Disease

The aim of the application of continuous traction (using either a stretching device or a vacuum constriction device) for Peyronie’s disease is to increase the activity of degradative enzymes, which in turn leads to a loss of tensile strength and ultimately to plaque solubilisation.

Furthermore, a regular stretching may counteract the contracture due to scarring formation and may therefore reduce the progression of the curvature and the extent of penile shortening.

The main limit of traction therapy is that to be effective it needs to be continued for many hours on a daily basis and this may not be feasible for many patients.

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