Page 100 - Remedial Andrology

8.2.3.1.6 Recommendations for non-operative treatment of Peyronie’s disease

Recommendations Strength rating
Offer conservative treatment to patients not fit for surgery or when surgery is not acceptable Strong
to the patient.
Discuss with patients all the available treatment options and expected results before Strong
starting any treatment.
Do not offer oral treatment with vitamin E, potassium para-aminobenzoate (potaba), Strong
tamoxifen, pentoxifylline, colchicine and acetyl esters of carnitine to treat Peyronie’s disease
(PD).
Nonsteroidal anti-inflammatory drugs can be used to treat penile pain in the acute phase of Strong
PD.
Extracorporeal shockwave treatment (ESWT) can be used to treat penile pain in the acute Weak
phase of PD.
Phosphodiesterase type 5 inhibitors can be used to treat concomitant erectile dysfunction or Weak
if the deformity results in difficulty in penetrative intercourse in order to optimise penetration .
Intralesional therapy with interferon alpha-2b may be offered in patients with stable Strong
curvature dorsal or lateral > 30˚ seeking a minimal invasive procedure.
Intralesional therapy with collagenase clostridium histolyticum CCH may be offered in Strong
patients with stable PD and dorsal or lateral curvature > 30º, who request non-surgical
treatment, although the placebo effects are high.
Do not offer intralesional treatment with steroids to reduce penile curvature, plaque size or Strong
pain.
Do not offer ESWT to improve penile curvature and reduce plaque size. Strong
Penile traction devices and vacuum devices may be offered to reduce penile deformity or as Weak
part of a multimodal therapy approach, although outcome data is limited.

8.2.3.2 Surgical treatment
Although conservative treatment for PD may resolve painful erections in most men, only a small percentage
experience significant straightening of the penis. The aim of surgery is to correct curvature and allow
penetrative intercourse. Surgery is indicated in patients with significant penile deformity and difficulty with
intercourse associated with sexual bother. Patients must have a stable disease for 3-6 months (or more than
9-12 months after onset of PD) [993, 1002, 1089]. In addition to this requirement, there are other situations that
may precipitate an indication for surgery, such as failed conservative or medical therapies, extensive penile
plaques, or patient preference, when the disease is stable [1090, 1091].

Before considering reconstructive surgery, it is recommended to document the size and location of penile
plaques, the degree of curvature, complex deformities (hinge or hourglass), the penile length and the presence
or absence of ED. The potential aims and risks of surgery should be fully discussed with the patient so that he
can make an informed decision [1089]. Specific issues that should be mentioned during this discussion are:
risk of penile shortening; ED, penile numbness; and delayed orgasm, the risk of recurrent curvature, potential
for palpation of knots and stitches underneath the skin, potential need for circumcision at the time of surgery,
residual curvature and the risk of further penile wasting with shortening procedures [1002, 1092]. Selection of
the most appropriate surgical intervention is based on penile length assessment, curvature severity and erectile
function status, including response to pharmacotherapy in cases of ED [1002]. Patient expectations from
surgery must also be included in the pre-operative assessment. The main objective of surgery is to achieve
a “functionally straight” penis, and this must be fully understood by the patient to achieve the best possible
satisfaction outcomes after surgery [1089, 1093].

Three major types of reconstruction may be considered for PD: (i) tunical shortening procedures;
(ii) tunical lengthening procedures; and, (iii) penile prosthesis implantation, with or without adjunct straightening
techniques in the presence of concomitant ED and residual curvature [1094, 1095].

Tunical shortening procedures achieve straightening of the penis by shortening the longer, convex side of the
penis to make it even with the contralateral side. Tunical lengthening procedures are performed on the concave
side of the penis after making an incision or partial excision of the plaque, with coverage of the defect with a
graft. Although tunical lengthening procedures rarely lead to long-term penile length gain, they aim to minimise
penile shortening caused by plication of the tunica albuginea, and correct complex deformities. In practice,
tunical lengthening procedures are often combined with penile plication or shortening procedures to correct

SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021 99