2018 CUA GL on Peyronie's disease and Congenital Penile Curvature

Question 1

What are manifestations of PD and where are the fibrotic changes?

Answer 1

Fibrotic changes in Tunica Albuginea

penile curvature, plaque, penile shortening, narrowing, indentation, hinging, erectile dysfunction, penile pain

Question 2

what is the natural history of PD?

Answer 2

Pain improves in most people. At 12 months: curvature gets better in around 10%. in many patients stable and in some patients gets worse( 20-40%)

Question 3

When should one give ICI during the work up of PD?

Answer 3

prior to invasive intervention and if patient is unable to provide digital images at full rigidity( by himself or with the help of PDE5i)

Question 4

what are the three domains of PDquestionarie(PDQ)

Answer 4

Physical/psychological bother, penile pain, symptom bother

Question 5

How should penis be examined for PD?

Answer 5

on stretch, feel for location, size, number and tenderness of the plaques. determine stretched penile length

Question 6

How is stretched penile length determined?

Answer 6

from penopubic skin junction to coronal sulcus or the tip

Question 7

what kind of PD would cause penile shortnening?

Answer 7

bilateral plaques, plaques within the inter-cavernosal septum.

Question 8

what is the gold standard for examination of PD?

Answer 8

office ICI( especially for people reporting complex multidirectional or hour glass deformity) or ED

Question 9

What investigations can be offered for PD?

Answer 9

once again office ICI is very helpful. ALSO color doppler US too

Question 10

What US findings are good prognosticators what are bad prognosticators?

Answer 10

Solitary, less calcified and
dense plaques were predictors of future disease stability as
compared to multiple, dense calcified plaques, which portend
a poorer prognosis

Question 11

is the use of MRI supported for routine evaluation of PD

Answer 11

NO

Also CT doesn’t have role either

Question 12

Any role of blood tests

Answer 12

No, not typically

Question 13

Is there a threshold for PD that requires intervention?

Answer 13

No,

but most men with curvature less than 30 degrees have normal function

Question 14

Which of the following agents is recommended for treatment of PD in Canada? Vitamin E, Tamoxifen, procarbazine, Vitamin E/L-carnitine.

Answer 14

None

Question 15

What are oral agents that may be used for PD?

Answer 15

potassium para-amino-benzoate, co-enzyme Q10, pentoxyfylline. ( the evidence is not that good, dont delay care bc of these) , can be part of multimodal therapy

Question 16

Is there a role for 5mg daily tadalafil for PD?

Answer 16

one study shows it slows plaque progression, more studies are needed.

Question 17

How can pain be treated for PD?

Answer 17

minimize uncomfortable sex positions, NSAIDs for penile pain, ESWL

Question 18

IS there a role for use of iontophoresis for management of PD?

Answer 18

nope

There is no role for topical verapamil.

Question 19

What are first and second line intralesional treatments for PD?

Answer 19

first line: clostridial collagenase( Xiaflex)

Second line: Interferon or verapamil

Question 20

Based on IMPRESS I and II study who are ideal candidates for Xiaflex?

Answer 20

Men with curvature 30-90 degrees, no hourglass deformity, normal erectile function, stable disease

Question 21

How big of an improvement one may expect with Xiaflex?

Answer 21

34% as per IMPRESS I AND II study

Question 22

what are side effects of Xiaflex?

Answer 22

Penile hematoma, penile pain, penile swelling, corporal rupture.

Question 23

what will IFN do for PD?

Answer 23

improved curvature and plaque size. a new study looking at IFN α2β showed it improved penile curvature without affecting penile vascular parameters

Question 24

what are common side effects of IFN α2β?

Answer 24

sinusitis, flulike symptoms, arthralgias, fever and chills + local side effects

Question 25

who can have IFN α2β?

Answer 25

men with curvature of at least 30 degrees, non-calcified plaque, modest efficacy

Question 26

are corticosteroids recommended for intralesional treatment?

Answer 26

No

Question 27

Is there a role for Botox or intralesional hyaluronic acid?

Answer 27

No, some early evidence but not recommended yet

Question 28

Is there a role for Stem cell therapy or platelet rich plasma?

Answer 28

No, they are still in research stages

Question 29

Is penile traction recommended as part of PD Tx?

Answer 29

yes

It helps change collagen and MMP which helps with tissue remodeling

Question 30

What does mechanical traction help with?

Answer 30

pain, curvature, maintenance of length. works in synergy with intralesional therapies.

Question 31

What is the role of ESWT in PD?

Answer 31

there is evidence it helps with penile pain. however no evidence it helps improve penile curvature or plaque size

Question 32

IS there a role for use of RT for treatment of PD?

Answer 32

No

Question 33

Name three surgical treatments for PD?

Answer 33

penile plication, penile plaque incision/excision and grafting, penile prosthesis implantation.

Question 34

How long after disease onset before surgery?

Answer 34

6-12 months with disease stability for 3-6 months

Question 35

what imaging study is recommended in preoperative period?

Answer 35

color doppler US with ICI is gold standard.

Question 36

when can you skip CDU and ICI?

Answer 36

if there is a full erection present on preop images.

Question 37

What is functionally straight for PD?

Answer 37

curvature less than 20 degrees( penetration not compromised)

Question 38

What are common side effects with PD surgery?

Answer 38

persistent or recurrent deformity, penile length loss, ED(decreased rigidity), sensory changes, orgasm/ejaculation changes( not sure why)

Question 39

Who is a candidate for plication surgery?

Answer 39

men with adequate penile length, good erections( even with PDE5i), minimal/absent hourglass deformity.

Question 40

Who is a candidate for grafting techniques?

Answer 40

> 60 degree curve, with men intact erections with severe curvature, indentation or hourglass deformity, concern for functional length loss with plication surgery

Question 41

who should get an IPP?

Answer 41

preferred for men with complex penile deformities not amenable to plication or grafting. patients with refractory ED.

Question 42

should synthetic grafts be used in patients having grafting done?

Answer 42

NOO

Question 43

Should you excise the whole plaque?

Answer 43

you can but partial excision or incision is preferred to minimize the risk of veno-occlusive permanent ED

Question 44

Where are 4 sites that you can harvest graft from?

Answer 44

Fascia lata, saphenous vein, temporalis fasica, tunica vaginalis.

Question 45

What are some typical findings in congenital penile curvature?

Answer 45

usually ventral, usually normal erections, lifelong curvature, no underlying plaque present young, simple deformity

Question 46

What is the treatment for CPC?

Answer 46

Surgical ( if it is an issue)- plication as per GL, no role for medical therapy