AUA Peyronie’s guideline: Dr. Burnett offers highlights

Linthicum, MD-The recently published AUA practice guideline on Peyronie’s disease provides current clinical principles on diagnosis and treatment of a highly prevalent and clinically significant condition, according to the co-chair of the multidisciplinary panel that developed the guideline.

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Peyronie’s disease (PD) is defined by the guideline panel “as an acquired penile abnormality characterized by fibrosis of the tunica albuginea, which may be accompanied by pain, deformity, erectile dysfunction, and/or distress.” In published studies, the condition’s prevalence ranges from 0.5 to 20.3%, a wide variation that depends on individual study factors, including how PD is defined and how men are queried. The rate may be higher in men with comorbid conditions, the panel wrote, and recent studies suggest that its prevalence has been historically underestimated.

Dr. Burnett“I think a guideline in Peyronie’s disease is timely, with the development of therapies that seem to meet level 1 evidence. Certainly this is a condition that we’re recognizing by epidemiologic studies has high prevalence and high significance. It impacts a lot of men,” said Arthur L. Burnett, II, MD, MBA, professor of urology at Johns Hopkins University School of Medicine, Baltimore.

The guideline was initially presented at the AUA annual meeting in New Orleans and was subsequently published in the Journal of Urology (2015; 194:745–53). Its evidence-based statements are divided into sections on diagnosis and treatment. Highlights include the following.

Next: Dr. Burnett discusses guideline in video

Diagnosis

“The urologist or clinician should be prepared to carry out a proper evaluation of the patient, and that includes clinical history taking, physical examination, and counseling the patient,” Dr. Burnett told Urology Times.

Among the specific recommendations:

• Clinicians should engage in a diagnostic process to document the signs and symptoms that characterize PD. The minimum requirements for this examination are a careful history (to assess penile deformity, interference with intercourse, penile pain, and/or distress) and a physical exam of the genitalia (to assess for palpable abnormalities of the penis).

• Clinicians should perform an in-office intracavernosal injection test with or without duplex Doppler ultrasound prior to invasive intervention.

• Clinicians should evaluate and treat a man with PD only when they have the experience and diagnostic tools to appropriately evaluate, counsel, and treat the condition.

Next: Treatment

Treatment

Among the clinical principles for first-line treatment are the following:

• Clinicians should discuss with patients the available treatment options and the known benefits and risks/burdens associated with each treatment.

• Clinicians should not offer oral therapy with vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or a combination of vitamin E with L-carnitine.

• Clinicians may administer intralesional collagenase clostridium histolyticum (CCH [XIAFLEX]) in combination with modeling by the clinician and by the patient for the reduction of penile curvature in patients with stable PD, penile curvature >30° and <90°, and intact erectile function (with or without the use of medications).

• Clinicians should counsel patients prior to beginning treatment with intralesional CCH regarding potential occurrence of adverse events, including penile ecchymosis, swelling, pain, and corporal rupture.

• Clinicians may administer intralesional interferon α-2b in patients with PD.

• Clinicians may offer intralesional verapamil for the treatment of patients with Peyronie’s disease.

• Prior to beginning treatment with intralesional interferon α-2b or intralesional verapamil about potential adverse events. For interferon α-2b, these events include sinusitis, flu-like symptoms, and minor penile swelling. For example, adverse events may include penile bruising, dizziness, nausea, and pain at the injection site.

• Clinicians should not use extracorporeal shock wave therapy (ESWT) for the reduction of penile curvature or plaque size. However, ESWT may be offered to improve penile pain.

• Clinicians should assess patients as candidates for surgical reconstruction based on the presence of stable disease.

• Clinicians may offer tunical plication surgery to patients whose rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) to improve penile curvature.

• Clinicians may offer plaque incision or excision and/or grafting to patients with deformities whose rigidity is adequate for coitus (with or without pharmacotherapy and/or vacuum device therapy) to improve penile curvature.

• Clinicians may offer penile prosthesis surgery to patients with Peyronie’s disease with erectile dysfunction and/or penile deformity sufficient to prevent coitus despite pharmacotherapy and/or vacuum device therapy.

• Clinicians may perform adjunctive intra-operative procedures, such as modeling, plication, or incision/grafting, when significant penile deformity persists after insertion of the penile prosthesis.

“I think the guideline brings awareness to the condition overall,” Dr. Burnett said, “and it should help guide us about where we do have gaps in our knowledge and gaps in the care we currently have available and may help derive future directions for treating patients with Peyronie’s disease.”

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