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

© The Canadian Journal of Urology TM : International Supplement, August 2020 that 92% of the PTX treatment group demonstrated plaque improvement/stabilization compared to 44% in the no treatment group. 14 Coenzyme Q10 (CoQ10) has also had newer data suggesting its efficacy and safety for PD treatment. Safarinejad performed a double-blind, placebo-controlled randomized study and found significantly reduced curvature and plaque size, and increased International Index of Erectile Function (IIEF) scores in the CoQ10 group compared to placebo, with no significant effects on pain. 15 Colchicine and potassium aminobenzoate have also been studied in the literature; however, data are limited with varying results, requiring further investigation with larger randomized controlled trials. As for other oral therapies, AUA guidelines recommend against the use of vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, and combination vitamin E with L-carnitine due to the lack of compelling evidence suggesting their efficacies. 10 With any oral medication, patient compliance may prove to be an issue, thereby warranting appropriate patient counseling while determining the best treatment plan for these patients. Limited studies have been performed evaluating topical therapies for PD. Fitch et al performed a randomized placebo-controlled pilot study which found that topical verapamil hydrochloride 15% gel improved curvature and reduced plaque compared to placebo at 9 months follow up. 16 Topical liposomal recombinant human superoxide dismutase has also been shown to improve pain, curvature, and plaque size. 17,18 Future studies with larger patient cohorts need to be performed to further investigate these potentially promising topical therapy options. Current guidelines do not suggest their use as a treatment for PD. 10 Injection therapies Intralesional injection therapy has been widely studied in the literature and include collagenase clostridium histolyticum (CCh), interferon- α 2b, and verapamil. CCh targets collagen within plaques and works to break them down to improve curvature and deformities. CurrentAUAguidelines recommendCCh to be performed with clinician/patient modeling in PD patients during the passive phase with curvature 30°-90° in the dorsal, lateral, or dorsal/lateral planes with intact erectile function (with or without the use of medications). 10 These recommendations are based largely on the results of the double-blind, randomized, placebo-controlled IMPRESS (Investigation for Maximal Peyronie’s Reduction Efficacy and Safety Studies) I and II trials which facilitated approval by the Food and DrugAdministration. 19 The IMPRESS trials found significant improvement in penile curvature deformity with similar results when stratified by degree of baseline deformity (30°-60° or 61°-90°). Post hoc meta-analysis of the two trials revealed a mean 34% improvement in penile curvature in the CCh group compared to a mean improvement of 18.2% in the placebo treated men (p < 0.0001). Additionally, PDQ-bother score was significantly improved in the treatment group compared to placebo (-2.8 +/- 3.8 versus -1.8 +/- 3.5; p = 0.0037). These results strongly demonstrated the safety and efficacy of CCh for the treatment of passive phase PD, at least within the inclusion criteria specified. Patients should be appropriately counseled on expectations, as CCh does not guarantee complete straightening of the penis. Additionally, due to the costs, side effects, and rigorous protocol, patients may elect to drop out early from treatment. Important adverse events identified included penile ecchymosis (80%), swelling (55%), pain (45%), hematoma (< 1%), and corporal rupture (< 1%). Therefore, patient reassurance and regular follow up with patients is crucial as patients are often scared after adverse events. Regarding the more serious adverse event of corporal rupture following CCh, there is ongoing discussion on whether to manage these patients similar to that of traumatic penile facture or withmore conservative measures including observation and medical management. Recent studies have further explored the utility of CCh. To investigate its safety and efficacy during the active phase, Nguyen et al performed a retrospective study and found no statistically significant differences in final change in curvature between active and passive phase patients (16.7° versus 15.6°; p = 0.654) and in treatment-related adverse events (11% versus 10%; p = 0.778). 20 These results suggest that CCh may produce similarly safe and effective outcomes in treating PD in both active and passive phases. Another study targeted shortening the treatment protocol to assess safety andefficacy. Abdel Raheemet al published their results from a prospective study of 53 PD patients who received 3 CCh injections 4 weeks apart with daily combination homemodeling, stretching, and a vacuum device to mechanically stretch the plaque. 21 Their study showed significant improvements in IIEF (20.9 to 23.8; p < 0.001), PDQ-bother score (8.9 to 6.1; p < 0.01) andmeanpenilecurvature(31.4%improvement;p<0.01) after only 3 injections. These results suggest the treatment protocol may be shortened and refined with similarly effective results. Interferon- α 2b may also be a potential option and works by inhibiting fibroblast proliferation and increasing collagenase production, but may cause 13 Peyronie’s disease: what do we know and how do we treat it?