2018 CUA GL on Peyronie's disease and Congenital Penile Curvature Flashcards
What are manifestations of PD and where are the fibrotic changes?
Fibrotic changes in Tunica Albuginea
penile curvature, plaque, penile shortening, narrowing, indentation, hinging, erectile dysfunction, penile pain
what is the natural history of PD?
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%)
When should one give ICI during the work up of PD?
prior to invasive intervention and if patient is unable to provide digital images at full rigidity( by himself or with the help of PDE5i)
what are the three domains of PDquestionarie(PDQ)
Physical/psychological bother, penile pain, symptom bother
How should penis be examined for PD?
on stretch, feel for location, size, number and tenderness of the plaques. determine stretched penile length
How is stretched penile length determined?
from penopubic skin junction to coronal sulcus or the tip
what kind of PD would cause penile shortnening?
bilateral plaques, plaques within the inter-cavernosal septum.
what is the gold standard for examination of PD?
office ICI( especially for people reporting complex multidirectional or hour glass deformity) or ED
What investigations can be offered for PD?
once again office ICI is very helpful. ALSO color doppler US too
What US findings are good prognosticators what are bad prognosticators?
Solitary, less calcified and
dense plaques were predictors of future disease stability as
compared to multiple, dense calcified plaques, which portend
a poorer prognosis
is the use of MRI supported for routine evaluation of PD
NO
Also CT doesn’t have role either
Any role of blood tests
No, not typically
Is there a threshold for PD that requires intervention?
No,
but most men with curvature less than 30 degrees have normal function
Which of the following agents is recommended for treatment of PD in Canada? Vitamin E, Tamoxifen, procarbazine, Vitamin E/L-carnitine.
None
What are oral agents that may be used for PD?
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
Is there a role for 5mg daily tadalafil for PD?
one study shows it slows plaque progression, more studies are needed.
How can pain be treated for PD?
minimize uncomfortable sex positions, NSAIDs for penile pain, ESWL
IS there a role for use of iontophoresis for management of PD?
nope
There is no role for topical verapamil.
What are first and second line intralesional treatments for PD?
first line: clostridial collagenase( Xiaflex)
Second line: Interferon or verapamil
Based on IMPRESS I and II study who are ideal candidates for Xiaflex?
Men with curvature 30-90 degrees, no hourglass deformity, normal erectile function, stable disease
How big of an improvement one may expect with Xiaflex?
34% as per IMPRESS I AND II study
what are side effects of Xiaflex?
Penile hematoma, penile pain, penile swelling, corporal rupture.
what will IFN do for PD?
improved curvature and plaque size. a new study looking at IFN α2β showed it improved penile curvature without affecting penile vascular parameters
what are common side effects of IFN α2β?
sinusitis, flulike symptoms, arthralgias, fever and chills + local side effects
who can have IFN α2β?
men with curvature of at least 30 degrees, non-calcified plaque, modest efficacy
are corticosteroids recommended for intralesional treatment?
No
Is there a role for Botox or intralesional hyaluronic acid?
No, some early evidence but not recommended yet
Is there a role for Stem cell therapy or platelet rich plasma?
No, they are still in research stages
Is penile traction recommended as part of PD Tx?
yes
It helps change collagen and MMP which helps with tissue remodeling
What does mechanical traction help with?
pain, curvature, maintenance of length. works in synergy with intralesional therapies.
What is the role of ESWT in PD?
there is evidence it helps with penile pain. however no evidence it helps improve penile curvature or plaque size
IS there a role for use of RT for treatment of PD?
No
Name three surgical treatments for PD?
penile plication, penile plaque incision/excision and grafting, penile prosthesis implantation.
How long after disease onset before surgery?
6-12 months with disease stability for 3-6 months
what imaging study is recommended in preoperative period?
color doppler US with ICI is gold standard.
when can you skip CDU and ICI?
if there is a full erection present on preop images.
What is functionally straight for PD?
curvature less than 20 degrees( penetration not compromised)
What are common side effects with PD surgery?
persistent or recurrent deformity, penile length loss, ED(decreased rigidity), sensory changes, orgasm/ejaculation changes( not sure why)
Who is a candidate for plication surgery?
men with adequate penile length, good erections( even with PDE5i), minimal/absent hourglass deformity.
Who is a candidate for grafting techniques?
> 60 degree curve, with men intact erections with severe curvature, indentation or hourglass deformity, concern for functional length loss with plication surgery
who should get an IPP?
preferred for men with complex penile deformities not amenable to plication or grafting. patients with refractory ED.
should synthetic grafts be used in patients having grafting done?
NOO
Should you excise the whole plaque?
you can but partial excision or incision is preferred to minimize the risk of veno-occlusive permanent ED
Where are 4 sites that you can harvest graft from?
Fascia lata, saphenous vein, temporalis fasica, tunica vaginalis.
What are some typical findings in congenital penile curvature?
usually ventral, usually normal erections, lifelong curvature, no underlying plaque present young, simple deformity
What is the treatment for CPC?
Surgical ( if it is an issue)- plication as per GL, no role for medical therapy
