3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 treatment goals, therapeutic options, and expectations with the patient. In this review, we discuss the current landscape for thediagnosis,management, and treatment of PD, including medical (oral, topical, intralesional, external energy) and surgical (penile plication, plaque incision or excision, penile implant) treatments. Diagnosis The diagnosis of PD starts with a thorough history evaluating the presentation, duration and evolution of penile deformity and concomitant symptoms such as pain or discomfort. Bother or distress may also exist and manifest as interference with intercourse, changes in confidence, and changes in interpersonal relationships. Urologists may find utility in using the Peyronie’s Disease Questionnaire (PDQ) or other PD questionnaires, which have been shown to demonstrate valuable subjective data in conjunction with objective measurements. 7,8 Past medical history and family history are important to identify known risk factors and comorbidities associatedwith PD, including penile fracture or trauma, Dupuytren’s contracture, plantar fibromatosis, diabetes, cardiovascular disease, ED, and low testosterone; however, most patients do not report an exact inciting event. Physical exam should focus on the genitalia to assess for penile deformity, presence of palpable abnormalities, and location of pain or discomfort. Evaluation of the penis should be performed in both flaccid and erect states with baseline measurement of penile curvature documented based on visual estimate, home photography, and/or more objective measurements performed such as utilizing a protractor or goniometer. 9 While careful history and physical examination may be sufficient to diagnose PD and move towards medical management, current American Urological Association (AUA) guidelines recommend an intracavernosal injection test with or without duplex Doppler ultrasound prior to any invasive treatment (e.g., intralesional treatments, penile prosthesis placement, or surgery). 10 The intracavernosal injection test enables urologists to better assess the extent of penile deformity, plaque(s), and pain in the erect state, while the addition of duplex ultrasound can better characterize plaque size and/or density, differentiate between calcified and non-calcified plaques, and obtain information on the vascular integrity of the penis. It is also important toclinically identifyandcategorize whether the patient presents during the active or passive phase of PDas thiswill guide subsequent management. The active phase is characterized by dynamic and changing symptoms with patients presenting with penile and/or glanular pain or discomfort with or without erection. Penile deformity and plaque may not be fully developed, distress may be present, and erectile function may be compromised. Importantly, some patients may experience painless deformity as well as intact erectile function. While invasive treatment is not advised during this phase, urologists should carefully plan with patients to educate them on their treatment options, expectations, and goals, as well as PD natural history and timeline. The following phase is the passive phase, duringwhich symptoms have been clinically quiescent or unchanged for ≥ 3 months based on either patient report or cliniciandocumentation. Pain with or without erection may still be present but is less common. Also, penile deformity is now stable and no longer progressive. Understanding the natural history of PD enables urologists to better guide patients regarding disease progression and timeline, and patient expectations. Mulhall et al performed a study that followed 246 men with newly diagnosed PD who had no medical treatment. 11 The mean duration of PD at followupwas 18 months. Their results showed that all patients who initially reported penile pain had improvement; 89% of whom reported complete resolution at follow up. However, of the men who reported penile curvature, only 12% improved (mean change 15°), 40% remained stable, and 48%worsened (mean change 22°) at follow up. These results combined with more recent studies suggest that many or most patients will have resolution or improvement of penile pain over time without intervention, while curvature and/or other deformities aremuch less likely to improve naturally. 12,13 Therefore, patients should be counselled accordingly, and treatment options should be discussed to target patient goals. Treatments should not be offered in patients whose PD does not cause them bother, as the risks may outweigh the benefits. Medical treatments Oral and topical therapies During the active phase of PD, the only medication class recommended by current AUA guidelines are oral non-steroidal anti-inflammatory drugs (NSAIDs), which can be offered to patients in need of pain management. 10 However, it can prove difficult to anticipatorily take NSAIDs before sexual activity, due to its often-spontaneous nature. Pentoxifylline (PTX), a nonspecific phosphodiesterase inhibitor, is another oral medication with limited but promising scientific data. Smith et al reported in a retrospective cohort study Chung et al. 12