Peyronie’s Disease: A Review

Medical Treatment

Conservative therapy is the standard treatment of Peyronie’s disease. Patients with evolving disease should be treated medically until the disease has become stable, typically a period of at least 6 months but more commonly 12 months. A number of treatments have been offered to men over the years, beginning with Peyronie’s own use of mercury and mineral water. Unfortunately, there are few prospective, blinded, randomized, placebo-controlled studies with standardized outcomes of sufficient power to evaluate many of the proposed medical therapies. In evaluating medical therapies, as seen in , it must be remembered that the natural history of Peyronie’s disease includes spontaneous resolution of pain, typically within 6 months, and in some men a small improvement in penile curvature. Medical treatments are administered systemically, locally, or intralesionally.

Table 1

  • Systemic

    • Vitamin E

    • Potaba

    • Colchicine

    • Tamoxifen

    • Acetyl-L-carnitine

  • Intralesional

    • Verapamil

    • Collagenase

    • Interferons

  • Extracorporeal shock wave therapy

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Colchicine is an oral antimicrotubule agent that inhibits collagen secretion. It is administered at a recommended dose of 0.6 mg to 1.2 mg daily during the first week of treatment, then increasing up to 2.4 mg/d, in divided doses for a period of up to 3 months. The main adverse effect is gastrointestinal upset with diarrhea in up to one third of subjects. Other, more severe side effects include lowered blood counts and elevation of liver enzyme levels. In an uncontrolled study of 24 patients, colchicine was reported to decrease plaque size and improve penile curvature in 50% of patients.25

Potassium aminobenzoate (Potaba; Glenwood, Englewood, NJ) has been prescribed extensively for Peyronie’s disease.26 Its mechanism of action is not understood but may involve decreased fibrogenesis through altered serotonin levels. The drug is prescribed at 20 g/d for 3 months, although some practitioners give the drug for up to 12 months. This treatment is expensive and, in general, poorly tolerated. The most frequent reported side effect is gastrointestinal upset. In a review of 2653 patients, Potaba, in a non-controlled study, was reported successful in 57% of treated patients.27

Tamoxifen is thought to facilitate the release of TGF-β1 from fibroblasts and therefore to regulate the immune response.28 In a placebo-controlled study of 25 patients with Peyronies’s disease, there was no significant improvement in pain, curvature, or plaque size with tamoxifen, 20 mg twice daily, compared with placebo. Side effects of tamoxifen included gastrointestinal distress and alopecia.29 Acetyl-L-carnitine, 1 g twice daily, was compared with tamoxifen in a randomized study of 48 patients. With a short follow-up, the patients who received acetyl-L-carnitine had greater decreases in penile pain and plaque size, with fewer adverse effects, compared with those who received tamoxifen.30

Vitamin E is commonly used to treat Peyronie’s disease. In 1948, Scott and Scardino31 reported a beneficial effect in 23 men treated with a dosage of 200 mg/d to 300 mg/d. In 1990, a controlled study of vitamin E failed to demonstrate a significant difference in pain, bend, ability to have intercourse, and overall disease state compared with placebo.8 The proposed action of vitamin E is through its ability to scavenge free radicals like ROS. Many clinicians consider this inexpensive, virtually side effect-free drug a reasonable treatment to offer patients awaiting stabilization of disease, allowing the clinician to build a rapport with the patient.

Several intralesional therapies have been proposed and studied for the treatment of Peyronie’s disease. Steroids have been injected into plaque in an effort to exploit their anti-inflammatory properties. Several short-term studies have been reported with good responses; however, intralesional steroids have many local adverse effects, including tissue atrophy and thinning of skin.32 The use of intralesional steroids may help persistent plaque pain, but they should not be used to treat curvature.

Intralesional injection of the calcium channel blocker verapamil has been reported for the treatment of Peyronie’s disease.33 Calcium channel blockers affect cytokine expression associated with the early phases of wound healing and have been shown to increase the activity of collagenase.34 Verapamil, 10 mg in 10 mL of saline, is injected every other week for a total of 6 injections, with pain and bruising the most common reported adverse effects. In a recent prospective study of 156 men treated with intralesional verapamil, of those who completed the treatment, 60% had an objective decrease in curvature, 80% an increase in rigidity distal to the plaque, and 71% an increase in sexual function.35 This study is notable for objectively measuring penile curvature through dynamic penile duplex ultrasound and correlating these findings with subjective patient questionnaire results. Interestingly, those patients who responded to therapy included men with dynamic and stable disease and men with disease ranging from mild to severe.

Gelbard and colleagues36 reported on the use of intralesional collagenase in a double-blind, placebo-controlled trial, with some benefit over placebo for mild disease but no significant improvement in more severe curvature. Several clinical trials of intralesional interferons have been reported. Interferons inhibit fibroblast proliferation in culture and increase the production of collagenase.37 Most patients receiving this treatment report transient flu-like symptoms. One study reported favorable results,38 but this has not been borne out in another published report.39

Several topical therapies have been reported, often employing iontophoresis for drug delivery. Treatment cocktails have included orgotein, steroid, and verapamil.40 Improvement as measured by history and ultrasound was reported in 62% to 90% of patients, depending on the treatment group, but none of these studies have been controlled.

Local extracorporeal shock wave therapy (ESWT) has been studied. Clearly, this therapy aims to fracture the calcified plaques, but the effect this has on the pathophysiology of the disease is unclear. Abdel-Salam and colleagues41 treated 24 patients with between 4 and 10 sessions of ESWT and reported a 59% improvement. A recent study of 42 patients treated with at least 3 sessions of ESWT (3000 shock waves 0.11–0.17 mJ/mm2) reported subjective improvement in 81% of patients, with 14% claiming excellent results and 50% endorsing significant improvements.42

Up to 30% of men with Peyronie’s disease have concomitant ED. These patients should be treated no differently than patients with ED who do not have Peyronie’s disease. Most such patients are started out on oral phosphodiesterase therapy and, if this fails, intracorporeal injections are then prescribed. The manufacturers of injectable alprostadil specifically state that their product is contraindicated in men with Peyronie’s disease, but the reason for this is that up to 30% of men on long-term injectable therapy will develop palpable Peyronie’s disease- like nodules of the tunica albuginea. It is theoretically possible that repeat needle puncture could exacerbate Peyronie’s disease.

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