Definition

Peyronie’s disease is a psychologically and physically devastating disorder that is manifest by a fibrous inelastic scar of the tunica albuginea, resulting in palpable penile scar in the flaccid condition and causing penile deformity, including penile curvature, hinging, narrowing, and shortening, and painful erections. In spite of multiple treatment options offered since François de la Peyronie described Peyronie’s disease in 1743, this disorder remains a considerable therapeutic dilemma even to today’s practicing physicians.

Evaluation of the patient with Peyronie’s disease

Thorough evaluation of the Peyronie’s disease patient is essential not only to diagnose the disease correctly, but also to guide treatment. Currently, no universally accepted standardized evaluation for Peyronie’s disease exists, nor has a validated questionnaire been developed. A suggested guideline for initial evaluation of the Peyronie’s disease patient, including history, physical examination, and imaging analysis, has been recommended and is outlined below.

The subjective assessment begins with the patient interview. History should be focused on the onset and duration of symptoms, the patient’s presenting signs and symptoms, and the presence or absence of pain. It is particularly useful to elucidate whether the patient continues to experience pain at the time of the initial evaluation, since this may represent a man in the acute phase of the disease. Pain may be present with palpation or erection or during coitus, and these settings should be differentiated since they may indicate different etiologies or degrees of acute inflammation. The patient’s subjective curvature deformity should be noted. It should also be noted that up to 90 % of men with Peyronie’s disease may present with diminished rigidity. In our experience, up to 50 % of men with erectile dysfunction and Peyronie’s disease have reported the onset of erectile dysfunction preceding Peyronie’s disease. It is also important to know what, if any, prior Peyronie’s disease therapies the patient has undergone, as this may help to guide future treatment. A detailed past medical and sexual history should be part of the initial evaluation of every man with Peyronie’s disease. Medical history should focus on personal or family history of wound-healing disorders, including Dupuytren’s contracture, which is reported in up to 20 % of patients with Peyronie’s disease. Any risk factors for ED, such as dyslipidemia, hypertension, atherosclerotic disease, a history of tobacco use, and diabetes, should be queried. The patient’s baseline erectile function should be assessed using a validated questionnaire. Although a validated Peyronie’s disease questionnaire is still in development, the International Index of Erectile Function (IIEF) may be used to gauge the patient’s baseline sexual function.

The objective evaluation begins with the physical examination. Although the focus should be on the genital examination, an examination of the hands and feet is appropriate given the patient’s history. Measurement of penile length is critical, since the loss of penile length is not only a known complication of Peyronie’s disease, but is also a source of great concern among patients. The penis should be measured stretched in its flaccid state dorsally from pubis to corona or meatus. Note that the suprapubic fat pad should be compressed during measurement. Objective evaluation of curvature is best performed using penile duplex ultrasound after pharmacologic stimulation to produce a full erection equal to or better than the patient’s at home. Simple erection induction in the office will allow objective assessment of deformity. Duplex ultrasound will allow assessment of vascular flow rates, the degree of curvature as measured with a protractor, the presence and location of any Peyronie’s plaque (or plaques), and the presence of any hinge effect. In addition, plaque calcification can be assessed. Autophotography should not be used as the sole means for curvature measurement, as this modality can be inconsistent and inaccurate.

The final portion of the Peyronie’s disease evaluation is objective assessment of the patient’s erectile capacity and penile sensation. During duplex ultrasound the patient should be asked to grade their pharmacologic erection compared with home erections. In addition, biothesiometry is recommended to assess penile sensation. Using the distal phalanx of the index fingers as positive control and the ventral surface of bilateral thighs as negative control, the point at which vibratory sensation is appreciated should be measured on the midshaft bilaterally and on the glans.

Non-surgical therapy for Peyronie’s disease

Since the first description of Peyronie’s disease in the literature, physicians have been searching for medical therapy options with little confirmed success. Consistent successful medical therapies continue to evade the practicing urologist, although current research into the molecular pathophysiology of Peyronie’s disease may one day lead to a medical cure. Several non-surgical options, however, are currently available and may stabilize or reduce deformity and improve sexual function. The evaluation of their efficacy has been compromised by clinical trials that are small and, in most cases, without any placebo control. Data outcomes are difficult to interpret in the absence of a validated questionnaire, and in a disease in which spontaneous improvement has been noted in 5 – 12 % of patients. Below, the non-surgical options for treatment of the pain and curvature of Peyronie’s disease, including oral, topical, intralesional, external energy, and combination therapies, are presented in Table Non-surgical therapies for Peyronie’s disease:

Treatment Mechanism of action Comments
Oral
Vitamin E Antioxidant that theoretically reverses or stabilizes pathologic changes in the tunica albuginea Limited side-effects, low cost. Efficacy not proven
Colchicine Inhibits fibrosis and collagen deposition through inhibition of neutrophil microtubules Mixed reports of efficacy in non-controlled trials. Single randomized, controlled trial failed to show benefit. May cause gastrointestinal disturbances, including severe diarrhea
Potassium aminobenzoate Member of the vitamin B complex, thought to increase the activity of monoamine oxidase, thereby decreasing local serotonin levels, which may contribute to fibrogenesis Significant reduction in plaque size, but not curvature. Expensive, and difficult to tolerate due to gastrointestinal side-effects
Tamoxifen May reduce release of transforming growth factor-beta from fibroblasts and may block transforming growth factor-beta receptors, resulting in diminished fibrogenesis Efficacy not proven. Side-effects may include alopecia
Carnitine Believed to inhibit acetyl co-enzyme A Efficacy not proven, and more investigation is needed
L -Arginine Amino acid substrate in the formation of nitric oxide, which is thought to be lacking in PD tissue Improvement in plaque size and collagen – fibroblast ratio in a rat model. Well tolerated
Pentoxifylline Non-specific phosphodiesterase inhibitor that may reduce collagen levels in PD plaques Improvement in plaque size and collagen – fibroblast ratio in a rat model
Topical
Verapamil Increases extracellular matrix collagenase secretion and decreases collagen and fibronectin synthesis and secretion; decreases fibroblast proliferation When administered topically the drug does not appear to penetrate into the tunica albuginea
Intralesional
Corticosteroids Anti-inflammatory and cause reduction in collagen synthesis Treatment with corticosteroids is discouraged by the authors. Effects are unpredictable, and may cause atrophy and distortion of tissue planes
Collagenase Breakdown of collagen Statistically significant improvement in curvature has been noted in men with mild-to-moderate disease
Verapamil Increases extracellular matrix collagenase secretion and decreases collagen and fibronectin synthesis and secretion; decreases fibroblast proliferation Controlled and non-controlled trials show promise as improvements in plaque volume, pain, and curvature have been reported
Interferons Decrease the rate of proliferation of fibroblasts in Peyronie’s plaques in vitro , reduce production of extracellular collagen, and increase production of collagenase Recent encouraging results with reports of improvement in curvature and pain. Dosing regimens and side-effect profiles yet to be determined
External energy
Penile ESWT ESWT-induced inflammatory response with resultant plaque lysis, improved vascularity, and the creation of contralateral scarring No statistically significant improvement noted in curvature, plaque size, or pain
Electromotively administered verapamil with or without dexamethasone Effect of verapamil and corticosteroids discussed above. Electric current itself may have some beneficial effect on wound healing Objective improvements of plaque size and curvature have been noted. Adverse effects include erythema at electrode site
Combination therapy
Vitamin E plus colchicine Discussed above. Synergistic effect possible Improvements in curvature and plaque size have been noted
ESWT with intralesional verapamil injection Discussed above. Synergistic effect possible Significant improvement in plaque size compared with placebo
Intralesional verapamil with oral carnitine or tamoxifen Discussed above. Synergistic effect possible Statistically significant subjective improvement in curvature, plaque size, and erectile function in patients treated with carnitine and intralesional verapamil
Penile traction devices
FastSize ® penile extender Chronic traction forces may trigger scar remodeling and formation of new connective tissue Early results demonstrate reduction of curvature, increase in length, and improvement in hinge effect. Side-effects were limited to mild discomfort with the device

Oral therapies

Vitamin E

Vitamin E was the first oral therapy to be described for the treatment of Peyronie’s disease. Vitamin E is a fat-soluble vitamin that is metabolized in the liver and excreted in bile and is thought to have antioxidant properties in humans. Oxidative stress and the production of reactive oxygen species (ROS) is known to be increased during the acute and proliferative phases of wound healing, since it is neutrophils and macrophages that produce these ROS, and the inflammatory phase of wound healing has been shown to be prolonged in patients with Peyronie’s disease. Thus, a biochemical rationale does exist for vitamin E use. Gelbard et al. compared vitamin E therapy to the natural history of Peyronie’s disease in 86 patients; no significant differences were found between the two groups in terms of curvature, pain, or the ability to have intercourse. In 1983, Pryor et al. performed a double-blind, placebo-controlled, crossover study evaluating vitamin E for the treatment of Peyronie’s disease in 40 patients. No significant improvements were noted in plaque size or penile curvature. More recently, Safarinejad et al. published a double-blind, randomized trial of vitamin E with or without proprionyl- L-carnitine (PLC) for the treatment of early Peyronie’s disease. Patients were randomly assigned to receive vitamin E, PLC, vitamin E plus PLC, or placebo. No significant improvement in pain, curvature, or plaque size was noted in any active treatment group compared with placebo.

In the opinion of the authors, vitamin E is not recommended for the treatment of Peyronie’s disease since there is no evidence of benefit in placebo-controlled trials.

Colchicine

Colchicine is an anti-gout medication that inhibits fibrosis and collagen deposition primarily by inhibiting the inflammatory response through inhibition of neutrophil microtubules. Colchicine has been used both as primary oral therapy for Peyronie’s disease as well as in combination with other modalities. Akkus et al. administered an escalating dose of colchicine in a non-randomized, non-placebo-controlled fashion to 19 patients with Peyronie’s disease over a 3 – 5 month period. Thirty-six percent of the patients noted a reduction in curvature, and 63 % noted an improvement in the palpable plaque. Seventy-eight percent of the patients who were experiencing painful erections at the time of treatment initiation had resolution of this symptom. Kadioglu et al. treated 60 patients with Peyronie’s disease using colchicine 1mg twice daily, with a mean follow-up of 11 months. They found significant improvement in pain in 95 % of men; however, 30 % of patients reported improved curvature while 22 % of patients reported worsened curvature. Safarinejad performed a randomized, placebo-controlled trial of colchicine in 2004 with 84 men. It was found that colchicine is no better than placebo at improving pain, curvature angle, or plaque size as measured by ultrasound.

Colchicine is not recommended by the authors owing to its lack of demonstrated efficacy in placebo-controlled trials. The agent is also associated with gastrointestinal distress, including diarrhea, and rarely with aplastic anemia.

Potassium aminobenzoate

Potassium aminobenzoate is a member of the vitamin B complex that is believed to increase the activity of monoamine oxidase in tissues, thereby decreasing local levels of serotonin and thus possibly decreasing fibrogenesis. Potassium amino-benzoate is used for other conditions, including scleroderma, dermatomyositis, and pemphigus. Zarafonatis and Horrax first described the use of potassium aminobenzoate for the treatment of Peyronie’s disease, and a subsequent European study published in 1978 reported a 57 % improvement rate with 9 % complete resolution in a pooled cohort of 2653 patients. This study, however, did not include a control or placebo group. In 1999, Weidner et al. published a randomized, placebo-controlled trial of potassium aminobenzoate 3g orally, four times per day for 1 year, in 103 men. The only significant difference found between the two groups was plaque size, which was not shown and has not been shown to correlate with a decrease in penile curvature. A 2005 follow-up study, also by Weidner et al., suggested that the use of potassium amionobenzoate may protect against progression of Peyronie’s disease plaques. Potassium aminobenzoate is expensive, and has low tolerability owing to gastrointestinal side-effects. It is also not recommended by the authors because of a lack of evidence regarding its efficacy in the treatment of Peyronie’s disease.

Tamoxifen citrate

Tamoxifen is a non-steroidal antiestrogen that acts by competing with estrogen binding sites in target tissues. In addition, tamoxifen affects the release of transforming growth factor (TGF)-beta from fibroblasts and blocks TGF-beta receptors, thus potentially reducing fibrogenesis. In 1992, Ralph et al. investigated tamoxifen in 36 patients with recent-onset Peyronie’s disease (duration less than 4 months). Eighty percent of the patients reported a reduction in pain, 35 % reported a subjective reduction in curvature, and 34 % reported a decrease in plaque size. A follow-up study in 1999 by Teloken et al. failed to show any statistically significant difference between tamox-ifen and placebo, and there was a reported increase of alopecia in the active treatment group.

We do not recommend the use of tamoxifen.

Carnitine

Carnitine is a naturally occurring metabolic intermediate. Carnitine facilitates the entry of long-chain fatty acids into muscle mitochondria, which are then used as energy substrate. Carnitine is also thought to inhibit acetyl co-enzyme A, which may aid in the repair of damaged cells. Biagiotti and Cavallini examined the use of carnitine for Peyronie’s disease in 2001. Forty-eight men were divided into two groups to receive either tamoxifen 20mg twice daily for 3 months or acetyl-L-carnitine 1g twice daily for 3 months. Overall, the men taking carnitine saw greater improvement in curvature and had statistically significant improvement in pain. In addition, the patients taking carnitine reported far fewer side-effects than the patients taking tamoxifen.

More study is needed to elucidate the role of carnitine in the treatment of Peyronie’s disease.

L -Arginine

L -Arginine is an amino acid that, when catalyzed by nitric oxide synthase (NOS), combines with oxygen ultimately to form nitric oxide (NO). It is known that inducible NOS (iNOS) is expressed in the fibrotic plaques of Peyronie’s disease, and that long-term suppression of iNOS exacerbates tissue fibrosis. In 2003, Valente et al. reported that L -arginine, given daily in the drinking water of a rat model with TGF-beta-1-induced Peyronie’s disease plaques, resulted in an 80 – 95 % reduction in plaque size and in the collagen – fibroblast ratio. In addition, L-arginine was found to be antifibrotic in vitro. This suggests that L-arginine, as a biochemical precursor of NO, may be effective in reducing Peyronie’s disease plaque size.

Further human trials are needed before this agent can be strongly recommended.

Pentoxifylline

Pentoxifylline is a non-specific phosphodiesterase (PDE) inhibitor. Valente et al. found that normal human and rat tunica albuginea, as well as Peyronie’s disease plaque tissue, express PDE-5A-3 and PDE-4A, PDE-4B, and PDE-4D. In their in vitro study, Peyronie’s disease fibroblasts were cultured with pentoxifylline and were found to have increased cAMP levels and reduced collagen levels compared with controls. In addition, pentoxyfilline given orally to a TGF-beta-1-induced Peyronie’s disease rat model resulted in decrease in Peyronie’s disease plaque size and in the collagen – fibroblast ratio. Brant et al. reported a single case report of successful Peyronie’s disease treatment using pentoxifylline alone.

Further studies are required to make a definitive examination of pentoxifylline for the treatment of Peyronie’s disease; however its known biochemical effect and early animal-model success make it an attractive option for oral therapy.

Topical therapies

Verapamil

Interest in topical verapamil for the treatment of Peyronie’s disease followed its success as an intralesional agent (see below). It does not appear, however, that tunica albuginea tissue concentrations of verapamil are achievable through topical application. In 2002 Martin et al. demonstrated that application of 0.5mg of a 40mg/ml verapamil gel to the penile shaft at 10 p.m. the night before and 5 a.m. the morning of scheduled Peyronie’s disease surgery failed to result in measurable levels of the drug in the tunica albuginea. Of note, urine levels of verapamil obtained at the same time as the tissue samples did demonstrate verapamil concentration consistent with systemic absorption. A recent three-arm trial without a known placebo demonstrated benefit with topical verapamil, but this study was significantly compromised. Thus the use of verapamil as a topical agent for Peyronie’s disease is not recommended.

Intralesional therapies

Corticosteroids

The powerful anti-inflammatory effect of corticosteroids led to their early investigation as agents for intralesional therapy of Peyronie’s disease. In 1954, Bodner et al. reported improvement in 17 patients treated with intralesional hydrocortisone and cortisone. In 1975, Winter and Khanna showed no difference between patients treated with dexamethasone injections and the natural history of the disease. In 1980, Williams and Green published a prospective study using intralesional triamcinolone. All patients were observed for 1 year after study enrollment; during that time only 3 % of patients reported improvement. Triamcinolone was administered every 6 weeks for 36 weeks; 33 % of patients reported subjective improvement, particularly in pain and plaque size.

Currently, the use of intralesional corticosteroids is discouraged because of the side-effects of local tissue atrophy, fibrosis, immune suppression, and lack of objective measures of benefit.

Collagenase

Collagenase was first studied in vitro by Gelbard et al. in 1982. A subsequent clinical trial by that group demonstrated subjective improvement in 64 % of patients within 4 weeks of treatment. A decade after their initial study, they published their findings of a double-blind trial in 49 men. Statistically significant improvement in curvature was noted in the collagenase-treated group; however, maximal improvement ranged from 15 – 20 ° and was only seen in the patients with curvatures of less than 30 ° and plaques of less than 2cm in length. Larger-scale controlled trials of collagenase are currently in development.

Verapamil

Verapamil is a calcium-channel blocker that has been shown in in vitro studies to inhibit local extracellular matrix production by fibroblasts, to reduce fibroblast proliferation, to increase local collagenase activity, and to affect the cytokine milieu of fibroblasts. In 1994, Levine et al. reported on 14 men who underwent a dose-escalation trial of intra-lesional injections of verapamil every other week for 6 months. Significant improvement in plaque-associated narrowing was noted in all patients, and curvature was improved in 42 %.

The first randomized, single-blind trial of intralesional verapamil was published in 1998. Significant differences were noted in terms of erection quality and plaque volume. A trend towards improvement in curvature was also noted. As a follow-up, Levine and Estrada reported on 156 men enrolled in a prospective non-randomized trial of Peyronie’s disease men with a mean follow-up of 30.4 months. A local penile block was performed with 10 – 20ml bupivicaine 0.5 % , followed by injection of verapamil 10mg diluted in 6ml sterile normal saline (total volume 10ml) into the Peyronie’s plaque using between one and five skin punctures, but with multiple passes through the plaque. The goal is to leave the drug in the needle tracks but not to tear or disrupt the plaque. Injections were administered every 2 weeks for a total of 12 injections. Eighty-four percent of patients with pain achieved complete resolution, 62 % were found on objective measurement to have improved curvature ranging from 5 ° to 75 ° (mean 30 °), and only 8 % of patients had measured worsening of curvature.

More recently, Bennett et al. administered six intralesional injections (verapamil 10mg in 5ml) every 2 weeks to 94 consecutive patients with Peyronie’s disease. Follow-up was at an average of 5.2 months after completion of the sixth injection. Eighteen percent of patients (n = 17) were found to have improved curvatures (average improvement 12 °), 60% (n=56) had stable curvature, and 22 % (n= 21) had increased curvature (average increase 22 °). All patients with pre-treatment penile pain had improvement at follow-up. The authors suggest that these data support intralesional verapamil for the stabilization of Peyronie’s disease.

It may be that six injections provide stabilization but are insufficient to accomplish reduction of curvature. Currently, we recommend a trial of six injections, with injections occurring at 2-week intervals. If no improvement is noted by the patient, the therapy may be terminated, the verapamil dose can be increased to 20mg, or interferon injections may be offered. If improvement is reported, another six injections are given. We consider verapamil to be contraindicated in patients with ventral plaques or extensive plaque calcification.

Interferons

Duncan et al. reported in 1991 that interferons decrease the rate of proliferation of fibroblasts in Peyronie’s plaques in vitro , reduce the production of extracellular collagen, and increase the activity of collagenase. Initial studies performed by Wegner et al. demonstrated low rates of improvement, but a high incidence of side-effects, including myalgias and fever. In 1999, Ahuja et al. reported on 20 men who received 1×106 units of interferon-alpha-2b every other week for 6 months. One hundred percent of patients reported softening of plaque, 90 % of men presenting with pain had improvement, and 55 % had a subjective reduction in plaque size. Dang et al. administered 2×10 units to 21 men, twice weekly for 6 weeks and found objective curvature improvements in 67 % , and improvement in pain in 80 %. Seventy-one percent of patients reported improvement in erectile dysfunction symptoms. In 2006, Hellstrom et al. reported on a placebo-controlled, multicenter trial of 117 patients who underwent injections of 5×10 units every other week for a total of 12 weeks. Average curvature in the treatment group improved by 13 ° compared with 4 ° in the placebo arm, and 27 % of patients in the treatment group had measured improvement compared with 9 % of the saline group. Pain resolution was noted in 67 % of the treatment patients compared with 28 % of the placebo group.

Interferon therapy requires further investigation to determine adequately its efficacy, dosing regimens, and side-effect profiles before its routine use in Peyronie’s disease patients can be recommended.

External energy therapies

Penile electroshock wave therapy

Local penile electroshock wave therapy (ESWT) has been suggested to be helpful. Various hypotheses about its mechanism of action exist, including direct damage to the plaque resulting in an inflammatory reaction with increased macrophage reaction leading to plaque lysis, improved vascularity resulting in plaque resorption, and the creation of contralateral scarring of the penis resulting in ‘false’straightening. Hauck et al. randomized 43 men to ESWT or oral placebo for 6 months. No significant effect was noted in terms of curvature, plaque size, or subjective improvement in sexual function or rigidity. More recent work from a German group randomized 102 men to ESWT or to receive sham shocks. There was no statistically significant difference found between the groups for plaque size, improvement of deformity, or sexual function post-treatment. ESWT is not currently recommended as therapy for Peyronie’s disease.

Iontophoresis

Iontophoresis involves the transport of ions through tissue by means of an electric current. Several studies have investigated the efficacy of topically applied verapamil with or without dexamethasone with enhanced penetration using iontophoresis. In 2002, Levine et al. confirmed that vera-pamil was found within the exposed tunica albuginea by examining surgically retrieved tunica albuginea from patients after a single intra-operative exposure during plaque incision and grafting surgery. Di Stasi et al. recently reported on a prospective, randomized study of 96 patients treated with verapamil 5mg plus dexamethasone 8mg using iontophoresis versus lidocaine 2 % delivered electromotively. Forty-three percent of patients in the verapamil – dexamethasone group noted objective improvement in plaque size and curvature; no changes were noted in the lidocaine group. In 2005, Greenfield et al. reported on the use of verapamil 10mg versus saline iontophoresis. Patients were assessed using papavarine-induced erections prior to and 1 month after treatment. Sixty-five percent of patients in the verapamil group demonstrated improvement in curvature compared with 58 % in the saline group. Mean curvature improvement was 9.1 ° in the treatment group compared with 7.6 ° in the saline group, which is clearly not as robust a response as reported with intralesional verapamil injections. The authors suggested that the electric current itself may have some beneficial effect on wound healing, which is known and supported in the dermatologic literature. Investigation into iontophoresis is ongoing.

Combination therapy

Vitamin E and colchicine

A placebo-controlled study by Preito Castro et al. randomized 45 patients to receive vitamin E plus colchicine or ibuprofen. Statistically significant improvements in curvature and plaque size were noted in the group treated with vitamin E plus colchicine compared with the group receiving ibuprofen. Patients in the vitamin E plus colchicine arm reported a greater decrease in pain, although this did not reach statistical significance.

Penile electroshock wave therapy with intralesional verapamil injection

In 1999, Mirone et al. prospectively examined two groups of Peyronie’s disease patients; one group was treated with ESWT, while the other received ESWT plus perilesional verapamil injections. A 52 % improvement in plaque size by ultrasound was noted in the ESWT-only group compared with 19 % in the combination-therapy group. A follow-up study by the same investigators involving 481 patients demonstrated a 49 % improvement in plaque size among those treated with the combined therapy.

Intralesional verapamil with oral carnitine or tamoxifen

In 2002, Cavallini et al. randomized 60 men to receive intra-lesional verapamil plus oral carnitine or intralesional vera-pamil plus oral tamoxifen. Statistically significant subjective improvements in curvature, plaque size, and erectile function were found in the carnitine group. No difference in improvement of pain was found between the two groups.

Penile traction devices

The use of tissue expanders has long been a mainstay of treatment in the orthopedic, oral – maxillofacial, and plastic surgical fields. It is well documented that gradual expansion of tissue results in the formation of new bone and connective tissue. Recently, initial work has been done to evaluate the efficacy of a penile extender device for the treatment of Peyronie’s disease. A pilot study of 10 patients at our institution found that daily application of the FastSize Medical ® device for 2 – 8 hours per day for 6 months resulted in a 33 % measured improvement in curvature (ranging from 10 ° to 45 ° improvement and resulting in an improvement in average curvature from 51 ° to 34 °), an increase in flaccid stretched penile length ranging from 0.5cm to 2.0cm, and an improvement in hinge effect in all those with advanced narrowing or indentation. No patients noted recurrence or worsening of curvature during 6 months of follow-up, and there was no incidence of local skin changes, ulceration, loss of sensation, or worsening of curvature. Long-term and larger studies are indicated.

Peyronie’s disease: Conclusion

Peyronie’s disease remains a treatment dilemma, in part owing to the lack of a clear understanding of its pathophysiology. It is hoped that, with further basic science research and properly conducted clinical trials, novel treatments will emerge. Currently we do not believe that oral therapy alone provides any real benefit with respect to correction of deformity, since it appears unlikely that an adequate concentration of any agent will reach the relatively hypovascular and hypocellular plaque, and placebo-controlled trials have not demonstrated benefit. On the other hand, injection of verapamil or interferon-alpha-2b has been shown to provide, at a minimum, stabilization of plaque and deformity progression, and it may improve sexual function as well. The newest non-invasive, non-surgical treatment with prolonged traction poses a novel approach based upon proven principles of tissue remodeling, and there have been encouraging preliminary results. We feel that it is possible to achieve a synergy with combination therapy using medical treatment (oral and injection) with its potential chemical effects, and the mechanical effects of traction therapy. This combination may result in the best chance for a non-surgical reduction in deformity with improvement in sexual function. Further studies will clearly be necessary.

Frederick L Taylor and Laurence A Levine

Selections from the book: “Textbook of Erectile Dysfunction”, 2009

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