Medical
therapy in Peyronie's Disease can play a role both in the acute and chronic
phase of the condition.
In the
acute phase, the aim of medical therapy is to promote a quicker resolution of
pain and inflammation in order to improve patient's quality of life and
minimize the damage in terms of deformity and penile shortening produced
by the plaque. In other words, during this phase, medical treatment should be
offered to limit the potential progression of Peyronie's Disease so that
surgery may not be needed, and if required, less invasive forms of surgical
procedures can be offered to correct the deformity.
In the
chronic phase of Peyronie's Disease, once the inflammatory process has settled
and the curvature has stabilized, the aim of medical therapy is to reduce the
degree of deformity and/or improve the quality of the erections in patients
with a degree of erectile dysfunction.
It is
paramount to keep in mind that around 9% of patients with Peyronie's Disease
will notice a progressive reduction in the severity of their penile deformity,
and that as a general role, any form of treatment is indicated only when
the deformity and/or the worsening of the quality of the erections renders
penetrative sexual intercourse uncomfortable or impossible.
Unfortunately none
of the conservative treatment options will work for every patient and therefore
a multi-modal approach should be always advised and should be tailored to
the unique indiidual profile of each patient.
With the
exception of injection of Collagenase Clostridium Histolyticum, patients need
to be aware that benefits of medical treatment during the chronic phase of
Peyronie's Disease are minimal.
Oral Medication for Peyronie’s
Disease
Although
a large number of oral medications and supplements have been proposed over
the years for the treatment of Peyronie’s Disease, none of these have
shown a significant therapeutic benefit when compared with placebo.
The most
common oral treatments for Peyronie's Disease are reported:
Vitamin E and
propionyl-L-carnitine in isolation and combination (Supplement)
Vitamin E
and propionyl-L-carnitine in isolation and combination have proven to be
completely ineffective for the treatment of Peyronie's Disease.
Colchicine (Prescription drug)
Colchicine
is an anti-gout agent that prevents the deposition of scar tissue ad therefore
has been prescribed to patients affected by Peyronie's Disease with the aim to
minimize scar formation. However, there is no clinical evidence that the
administration of Colchicine has any role in limiting the progression of
Peyronie's Disease.
Potassium aminobenzoate – POTABA
(Prescription drug)
Although
POTABA may play a minor role in inhibiting the progression of the plaques, it
is also associated with severe gastrointestinal side effects and therefore it
is not recommended.
Tamoxifen citrate (Prescription
drug)
This is
another compound that may potentially inhibit scar
formation but there is no clinical evidence of any benefit in
patients with Peyronie’s Disease.
Pentoxifylline (Prescription
drug)
Pentoxifylline administration
may result in a moderate reduction in plaque size and in penile curvature. The
cost of the medication is relatively low and although there are some potential
side effects, it is one of the treatments that patients can try during the
acute phase of Peyronie’s Disease with the aim to reduce progression.
Coenzyme Q10 and
Acetyl-L-carnitine (Supplement)
Coenzyme
Q10 and Acetyl-L-carnitine administration during the acute phase of Peyronie's
Disease may inhibit disease progression. However further studies
are required to see whether these two supplements are really effective in
this group of patients.
Phosphodiesterase
type 5 inhibitors
Phosphodiesterase
type 5 inhibitors (PDE5i) such as Viagra, Cialis and Levitra may also play
a role both in the acute and chronic phase of Peyronie's Disease. During the
acute phase these medications, by increasing the strength of erections, provide
a good stretch to the plaque and may play a role in limiting the potential
progression of the disease and minimizing the degree of penile shortening. Furthermore,
PDE5i may play locally a role at the level of the plaque by inhibiting the
deposition of scar tissue. In the chronic phase of Peyronie's
Disease instead, PDE5i may be useful in patients with a degree of erectile
dysfunction in order to guarantee the rigidity necessary to engage in
penetrative sexual intercourse.
Injection Therapy for Peyronie’s
Disease
Intralesional
injections of a variety of medications have been proposed in patients with
Peyronie’s disease. Over the years, the most commonly injected medication has
been Verapamil but there is no evidence of any significant benefit in patients
with Peyronie's Disease and therefore this practice should be discouraged.
Initial
medical trials of intralesional injections of Collagenase Clostridium
Histolyticum (Xiapex in Europe, Xiaflex in the USA) have shown promising
results and it is currently the only FDA (the government body responsible
for approving drugs in the US) approved medical treatment for Peyronie’s
disease.
Xiaflex
injections are already prescribed to treat Dupuytren’s contracture of the
palmar fascia, as this drug works by breaking down the collagen present in
the scar tissue of the plaque.
Currently
injections of Xiapex are indicated only for patients with dorsal and
dorsolateral curvatures. Xiapex injections in ventral plaques are not
recommended in order to avoid potential urethral injury. Injections should
also not be offered to patients with large calcified plaques due to the risk of
rupture of the needle in the hardened plaque.
Patients
need to be counselled that administration of Xiapex injections may produce a
reduction of the curvature of around 20-30% but not a complete correction of
the deformity. This degree of correction may not be particularly useful in
patients with severe curvatures, as a patient with 90 degrees of curvature
may expect to get down to around 60 degrees at the end of the cycle of
injections, but may allow patients with a moderate curvature
to avoid surgery.
Extracorporeal shock wave
treatment (ESWT) for Peyronie’s Disease
There is
no evidence that ESWT is beneficial in reducing the degree of curvature in
patients with Peyronie's Disease although there is some evidence that it may
reduce pain at the level of the plaque during the active phase of the
disease. Therefore, ESWT should not be considered an effective
treatment option for Peyronie’s Disease.
Traction and vacuum devices for
Peyronie’s Disease
The aim
of the application of continuous traction (using either a stretching device or
a vacuum constriction device) for Peyronie’s disease is to increase the
activity of degradative enzymes, which in turn leads to a loss of tensile
strength and ultimately to plaque solubilisation.
Furthermore,
a regular stretching may counteract the contracture due to scarring formation
and may therefore reduce the progression of the curvature and the extent of
penile shortening.
The main
limit of traction therapy is that to be effective it needs to be continued for
many hours on a daily basis and this may not be feasible for many patients.
