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    Streamlined management of Peyronie’s disease

    Quality of life impact, baseline erectile function will help guide optimal treatment strategy


    Treatment options

    Baseline erectile function significantly influences our treatment strategy. In the presence of severe ED, we advise patients to undergo placement of a penile prosthesis. Intraoperatively, curvature can be corrected via several methods. Prior to prosthesis placement, plication sutures can be placed after inducing an artificial erection with intracavernosal instillation of vasoactive agents such as alprostadil or Trimix (or saline) to fully delineate the curvature. Alternatively, once the device is placed, any significant remaining penile deformity can be corrected with modeling techniques or plaque excision/incision with or without grafting (table).

    Those without ED or those with ED fully responsive to medical therapy have an array of options available depending on degree of penile deformity and goals of care. Those with curvatures less than 30 degrees can be monitored without intervention, as such deformities are unlikely to preclude adequate sexual function. Recent guidelines have suggested the use of extracorporeal shock wave therapy (ESWT) to mitigate pain symptoms associated with PD. However, preliminary data suggest an improvement in penile pain after ESWT with conflicting data regarding improvement in penile curvature (J Sex Med 2013; 10:2815–21; Urol Ann 2016; 8:409-17).

    In patients suffering from simple curvatures ranging from 30 to 90 degrees, penile plication is an effective surgical approach that minimizes dissection and offers durable results. In our experience, we find that plication surgery is able to correct the majority of patients within this disease category. For this subset of patients, intralesional injection therapy with collagenase is also an efficacious management strategy for patients who elect not to undergo surgery. We have had excellent results with this therapy at our institution in appropriately selected patients.

    Graft types and common examples of grafts used in PD

    It is important to note that patients who initially elect for intralesional management of their PD but experience a poor result or desire further correction remain surgical candidates. Penile plication surgery is a straightforward procedure with minimal risk of de novo ED or reduced penile sensation secondary to handling of the neurovascular bundle (NVB) as more commonly seen with excision and grafting procedures. Significant complications associated with plication include penile shortening, recurrent penile curvature, an unstable penis, and palpable suture knots. Patients electing to undergo intralesional collagenase should also be counseled regarding the risk of corporal fracture, which is <1% based on trial data (J Urol 2013; 190:199-207).

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    Patients with multiplanar or destabilizing deformities and/or curvatures greater than 90 degrees generally require surgical reconstruction involving plaque excision or incision with defect correction utilizing grafting techniques. This approach must also be considered in patients with curvatures less than 90 degrees in whom plication may result in considerable penile shortening. The choice of graft material is largely dictated by surgeon preference and availability of the graft. The risks of de novo ED, reduced penile sensation secondary to NVB manipulation, and recurrence of penile curvature due to graft contracture must be explicitly discussed with the patient.

    A noteworthy factor to consider in the decision-making process is the cost of therapy. Thus, a thorough discussion regarding cost of intervention should be performed. Morey et al previously showed that penile plication has superior cost effectiveness compared with intralesional collagenase. According to industry data, most eligible patients with commercial insurance plans paid no co-pay for intralesional collagenase based on an analysis of 4,000 claims. For those without coverage, however, this therapy is likely cost prohibitive without industry assistance. Similarly, coverage for penile prosthesis placement is variable and frequently proves cost prohibitive for many patients (Urology Practice 2017; 4:118-25).


    In this article, we have attempted to provide a streamlined approach to the treatment and management of PD. PD remains a challenging disease entity to treat with a potential significant impact on a patient’s physical and psychological well-being. As several treatment options are available, familiarity with each technique is crucial to not only enhance outcomes but also to provide patients with the best opportunity to make informed decisions about treatment goals. Optimizing patient selection and selecting the ideal therapy based on disease severity and concurrent ED should be the focus of future research endeavors. The importance of clarifying a patient’s goals prior to any intervention cannot be understated.

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    Section Editor Christopher M. Gonzalez, MD, MBASection Editor Christopher M. Gonzalez, MD, MBA

    Dr. Gonzalez is professor and chairman of urology at University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland.


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