PEYRONIE’S DISEASE: AUA GUIDELINE (2015)

Question 1

Peyronie’s Algorithm

Answer 1

Question 2

What is the minimum requirement for diagnosing Peyronie’s disease?
a. Blood test
b. MRI
c. Physical exam and history
d. Urinalysis

Answer 2

c. Physical exam and history

Question 3

Which of the following treatments for Peyronie’s disease is not recommended?
a. Oral therapy with vitamin E
b. Intralesional collagenase clostridium histolyticum
c. Extracorporeal shock wave therapy
d. Intralesional verapamil

Answer 3

a. Oral therapy with vitamin E

Question 4

When is tunical plication surgery recommended for Peyronie’s disease?
a. When there is erectile dysfunction
b. When plaque incision or excision is not an option
c. When the rigidity is adequate for coitus
d. When there is significant penile deformity after insertion of a penile prosthesis

Answer 4

c. When the rigidity is adequate for coitus

Question 5

What are the signs and symptoms of Peyronie’s disease?

Answer 5

Peyronie’s disease is characterized by the formation of fibrous plaque on the tunica albuginea, which can cause penile curvature, pain, and difficulty with intercourse. Other symptoms may include a palpable lump or nodule on the penis and penile deformity.

Question 6

What is the diagnostic process for Peyronie’s disease?

Answer 6

The diagnostic process for Peyronie’s disease involves a careful history to assess penile deformity, interference with intercourse, penile pain, and/or distress, as well as a physical exam of the genitalia to assess for palpable abnormalities of the penis. An in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound may also be performed prior to invasive intervention.

Question 7

What are the available treatment options for Peyronie’s disease?

Answer 7

Treatment options for Peyronie’s disease include oral non-steroidal anti-inflammatory medications for pain management, intralesional collagenase clostridium histolyticum for the reduction of penile curvature, intralesional interferon α-2b, intralesional verapamil, and extracorporeal shock wave therapy for penile pain. Surgical options may include tunical plication surgery, plaque incision or excision and/or grafting, and penile prosthesis surgery for patients with erectile dysfunction and/or penile deformity sufficient to prevent coitus despite pharmacotherapy and/or vacuum device therapy.

Question 8

What are the potential adverse events associated with treatment for Peyronie’s disease?

Answer 8

The potential adverse events associated with treatment for Peyronie’s disease depend on the specific treatment. For example, patients treated with intralesional collagenase should be counseled about potential adverse events including penile ecchymosis, swelling, pain, and corporal rupture, while patients treated with intralesional interferon α-2b should be counseled about potential adverse events including sinusitis, flu-like symptoms, and minor penile swelling. Patients treated with intralesional verapamil may experience penile bruising, dizziness, nausea, and pain at the injection site. Clinicians should discuss the potential risks and benefits of each treatment option with patients before beginning treatment.

Question 9

What is Peyronie’s Disease characterized by?
a) Inflammation of the penile tissue
b) Fibrosis of the tunica albuginea
c) Enlargement of the prostate gland
d) None of the above

Answer 9

b) Fibrosis of the tunica albuginea

Explanation: Peyronie’s Disease is characterized by the development of fibrous plaques in the tunica albuginea of the penis, leading to deformity, pain, and erectile dysfunction.

Question 10

What are some of the common symptoms of Peyronie’s Disease?
a) Pain during erections
b) Curvature or bending of the penis
c) Erectile dysfunction
d) All of the above

Answer 10

d) All of the above

Explanation: Peyronie’s Disease can cause pain during erections, curvature or bending of the penis, and erectile dysfunction, among other symptoms.

Question 11

What is the prevalence rate of Peyronie’s Disease in a U.S. sample aged 18 years and older according to Dibenedetti (2011)?
A) 0.5%
B) 0.8%
C) 13.1%
D) 7.1%

Answer 11

C) 13.1%

Explanation: Dibenedetti (2011) reported a prevalence rate of 0.5% for men who had been formally diagnosed with PD, a rate of 0.8% for men who had been diagnosed or treated for PD, and a rate of 13.1% for men who had been diagnosed or treated or had any symptom of PD.

Question 12

What is the prevalence rate of Peyronie’s Disease in Italian men aged 50-69 years according to a population-based study?
A) 3.2%
B) 7.1%
C) 8.9%
D) 20.3%

Answer 12

B) 7.1%

Explanation: A population-based study in Italian men reported a prevalence rate of 7.1% among men aged 50-69 years.

Question 13

What is the most common inciting event for Peyronie’s Disease?
a) Infection
b) Aging
c) Trauma during sexual activity
d) Hormonal imbalance

Answer 13

c) Trauma during sexual activity

Question 14

What is the main pathology behind Peyronie’s Disease?
a) Increased collagen type 1
b) Increased elastin content in tunica
c) Fibrin trapping and macrophage recruitment
d) Decreased protein deposition in tunica

Answer 14

c) Fibrin trapping and macrophage recruitment

Question 15

Which of the following is a significant predictor of worsened curvature in men with Peyronie’s disease?
a) Age over 50 years
b) Presence of diabetes
c) Symptoms for less than six months
d) Plaque volume increase

Answer 15

b) Presence of diabetes
Explanation: Grasso (2007) followed 110 men annually for five years and found that the presence of diabetes was a significant predictor of worsened curvature.

Question 16

What are the predictors of worsened curvature in men with Peyronie’s disease, and how do these predictors differ in various studies?

Answer 16

In a study by Grasso (2007), the presence of diabetes was a significant predictor of worsened curvature in men with PD. In contrast, Berookhim (2014) found that men who experienced no change in curvature over 12 months without treatment were more likely to be older and to have had symptoms for greater than six months. These studies differ greatly in follow-up duration, with Grasso’s study lasting over six years and Berookhim’s study lasting only 12 months. The data suggest that the predictors of worsened curvature may vary depending on the study design and patient population.

Question 17

What percentage of men with PD indicate “emotional distress”?

Answer 17

As many as 81% of men with PD indicate “emotional distress”.

Question 18

What percentage of men with PD report relationship difficulties as a result of the condition?

Answer 18

More than half (54%) of men report relationship difficulties as a result of PD.

Question 19

What psychological sequelae can occur in men with PD?

Answer 19

One study reported that 48% of men with PD had clinically meaningful depressive symptoms, with 26% experiencing moderate symptoms and 21% experiencing severe symptoms.

Question 20

Why is it important to assess for distress in PD patients before and during treatment?

Answer 20

PD can have a profound negative impact on men’s QoL, with many men experiencing emotional distress, depressive symptoms, and relationship difficulties. Assessing for distress before and during treatment is important to ensure that patients receive appropriate support and care.

Question 21

What age group is most commonly affected by Peyronie’s Disease?
A. Children
B. Teenagers
C. Young adults
D. Mid-50s and above

Answer 21

D
Explanation: The most common presentation of Peyronie’s Disease is a male in his mid-50s who presents with recent onset of penile curvature accompanied by mild to moderate penile pain.

Question 22

What is the defining symptom of active Peyronie’s disease?
a. Erectile dysfunction
b. Penile and/or glanular pain or discomfort with or without erection
c. Penile induration
d. Palpable plaque

Answer 22

b. Penile and/or glanular pain or discomfort with or without erection

Explanation: The defining symptom of active Peyronie’s disease is penile and/or glanular pain or discomfort with or without erection.

Question 23

What distinguishes the patient with stable Peyronie’s disease from the patient with active disease?
a. Presence of erectile dysfunction
b. Duration of clinically quiescent or unchanged symptoms for at least three months
c. Palpable plaque
d. Ventral penile deformity

Answer 23

: b. Duration of clinically quiescent or unchanged symptoms for at least three months

Explanation: The patient with stable Peyronie’s disease has had clinically quiescent or unchanged symptoms for at least three months, while the patient with active disease has dynamic and changing symptoms.

Question 24

How does the presentation of stable Peyronie’s disease differ from active disease?

Answer 24

In the patient with stable Peyronie’s disease, symptoms have been clinically quiescent or unchanged for at least three months based on either patient report or clinician documentation. Pain with or without erection may be present but is less common. Stable disease means that the deformity is no longer progressive. Curvature may be uniplanar or biplanar and may not be dependent on the size and magnitude of the plaque. Plaque(s) can be palpated or documented on ultrasound. The most common plaque location is on the mid-shaft dorsal aspect of the penis toward the penile hilum or distally retrocoronal. The typical patient presents with a dorsal, dorso-lateral, or ventral penile deformity. Rarely rotational deformities may occur. There may be additional manifestations in the stable phase, including difficulty in maintaining erectile function and inability to sustain intercourse. Erectile function may be compromised by pain and/or deformity or may be reduced because of symptoms of ED not related to deformity or pain. It is reported that ED may be present in up to 33% of PD patients with greater than 50% of patients reporting that ED predated the onset of PD symptoms. Distress is generally present, and the degree of distress will depend on the patient’s perception of his symptom severity.

Question 25

What is the differential diagnosis for Peyronie’s Disease?
A) Congenital penile curvature
B) Dorsal penile vein thrombosis
C) Penile fracture
D) All of the above

Answer 25

D) All of the above

Question 26

How does congenital penile curvature differ from Peyronie’s Disease?
A) Congenital penile curvature is present from birth
B) Peyronie’s Disease has no penile plaque
C) Congenital penile curvature is often painful
D) Peyronie’s Disease presents in an acute time frame

Answer 26

A) Congenital penile curvature is present from birth

Question 27

Which condition presents with a popping sound during intercourse?
A) Congenital penile curvature
B) Dorsal penile vein thrombosis
C) Penile fracture
D) Primary penile cancer

Answer 27

C) Penile fracture

Question 28

What is the minimum requirement for a diagnostic examination of Peyronie’s disease?
A. Careful history only
B. Physical exam only
C. Both careful history and physical exam
D. Radiographic imaging

Answer 28

C. Both careful history and physical exam

Explanation: The AUA guideline states that the minimum requirement for a diagnostic examination of Peyronie’s disease is 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.

Question 29

What information should be elicited from the patient’s history?
A. Onset, precipitating factors, duration, changes over time, prior treatments used, and other conditions
B. Level of education, occupation, and marital status
C. Family history of PD and related conditions
D. All of the above

Answer 29

A. Onset, precipitating factors, duration, changes over time, prior treatments used, and other conditions

Explanation: The AUA guideline states that the clinician should meticulously elicit the patient’s history of penile symptoms, including onset, precipitating factors, duration, changes over time, prior treatments used, and other conditions (e.g., ED) that may affect treatment options.

Question 30

Why is assessment of sexual function important in patients with Peyronie’s disease?
A. To assess the patient’s overall health
B. To determine if the patient is sexually active
C. To assess the patient’s satisfaction with intercourse
D. To determine if the patient needs hormone replacement therapy

Answer 30

C. To assess the patient’s satisfaction with intercourse

Explanation: The AUA guideline states that assessment of sexual function is of particular importance in patients with Peyronie’s disease. Penile sensation, ejaculatory function, erectile function (including relevant comorbidities), difficulty/pain with penile penetration, and concerns regarding penile length and girth should be assessed. Patient and partner comfort and satisfaction with intercourse should also be assessed.

Question 31

What should be assessed during the physical exam of the genitalia?
A. Palpation of the scrotum
B. Documentation of the patient’s age
C. Measurement of stretched penile length
D. Examination of the testicles

Answer 31

C. Measurement of stretched penile length
Explanation: The physical examination of the genitalia should include stretching and palpation of the flaccid penis, documentation of circumcision status and any anomalies, and measurement of stretched penile length from the penopubic skin junction to the coronal sulcus or the tip to establish baseline penile length prior to any intervention.

Question 32

What is the recommended first step before initiating any invasive treatment for Peyronie’s Disease?
A. Physical examination of the genitalia
B. ICI test with duplex Doppler ultrasound
C. Home photography of the erect penis
D. Biothesiometry

Answer 32

B. ICI test with duplex Doppler ultrasound is recommended before initiating any invasive treatment for Peyronie’s Disease.

Question 33

What can be determined with an ICI test?
A. Presence of deformity, plaque, and pain in the erect state
B. Erectile function
C. Measurements of erect penile length and girth
D. All of the above

Answer 33

D. All of the above can be determined with an ICI test.

Question 34

Why is an ICI test recommended prior to invasive intervention for PD?

Answer 34

An ICI test is recommended prior to invasive intervention for PD as it enables assessment of penile deformity, plaque(s), and pain in the erect state. The point of maximum curvature can be determined, measurements of erect penile length and girth can be obtained, and erectile function can be assessed. When the ICI test is combined with duplex ultrasound, additional measurements of plaque size and/or density can be made, calcified and non-calcified plaques can be differentiated, and information on the vascular integrity of the penis can be obtained. In the patient with complex deformity (e.g., hourglass deformity or bidirectional curvature) and/or who reports ED, confirmation of these conditions with ICI is central to developing an effective treatment plan.

Question 35

How should a clinician evaluate and treat a patient with Peyronie’s disease?

Answer 35

The clinician should have the training, experience, and resources to conduct a full diagnostic evaluation, interpret the evaluation appropriately, and counsel the patient on the various treatment options. Treatment options may include medication, injection therapy, or surgery. The choice of treatment depends on the severity of the symptoms and the patient’s preferences. It is important to weigh the risks and benefits of each treatment option and involve the patient in the decision-making process. Follow-up care is also important to monitor the patient’s progress and adjust treatment as needed.

Question 36

What is the most important factor to consider when pursuing a treatment plan for Peyronie’s Disease?
A. Potential benefit to the patient
B. Severity of adverse events
C. Reversibility of adverse events
D. All of the above

Answer 36

D. All of the above

Explanation: According to the guideline, the clinician should carefully weigh the potential benefit to the patient of a particular treatment against that treatment’s risk for adverse events, the severity of adverse events, and the reversibility of adverse events.

Question 37

What is the range of average baseline curvature in published studies across intervention types for Peyronie’s Disease?
A. 1-10 degrees
B. 10-90 degrees
C. 90-180 degrees
D. There is no agreed-upon minimum curvature necessary prior to intervention.

Answer 37

B. 10-90 degrees

Explanation: According to the guideline, in published studies across intervention types that reported average baseline curvature, the range is 10 to 90 degrees, and the median is approximately 48 degrees.

Question 38

What is the importance of considering patient concern in the treatment decision-making process for Peyronie’s Disease?

Answer 38

Patient concern is an important component of the patient experience of Peyronie’s Disease. The distress over symptoms, penile appearance, and penile function can significantly affect the patient’s quality of life. Therefore, the patient’s level of concern regarding his symptoms and his willingness to undergo various types of treatment should be fully considered in the treatment decision-making process in addition to objective measures of curvature and erectile function. This can help to ensure that the patient is fully informed and involved in the decision-making process and that the chosen treatment plan is individualized to optimize sexual function and QoL.

Question 39

What is the main purpose of Guideline Statement 4?
a. To discuss the natural history of Peyronie’s disease with patients
b. To explain the available treatment options for Peyronie’s disease to patients
c. To provide a list of benefits and risks associated with each treatment option for Peyronie’s disease to patients
d. To encourage patients to choose a specific treatment option for Peyronie’s disease

Answer 39

: b. To explain the available treatment options for Peyronie’s disease to patients.

Explanation: The main purpose of Guideline Statement 4 is to discuss the available treatment options for Peyronie’s disease and the benefits and risks associated with each option.

Question 40

Why is it important for patients to have realistic expectations regarding the likely magnitude of treatment effects and the probability and type of adverse events?
a. To prevent patients from experiencing any negative side effects from treatment
b. To ensure that patients are fully informed about the potential risks and benefits of treatment
c. To increase patient satisfaction with the chosen treatment option
d. To speed up the healing process for Peyronie’s disease

Answer 40

c. To increase patient satisfaction with the chosen treatment option.

Explanation: Realistic expectations help patients to choose a treatment option that is right for them and to be satisfied with the outcome of the treatment.

Question 41

What is a hallmark symptom of active Peyronie’s disease?
a. Penile curvature
b. Erectile dysfunction
c. Pain with or without erection
d. Difficulty urinating

Answer 41

c. Pain with or without erection
Explanation: Pain is a common symptom of active Peyronie’s disease and can cause significant distress to the patient.

Question 42

How can a clinician assess the pain level of a patient with Peyronie’s disease?
a. Through blood tests
b. Through imaging studies
c. Through physical examination
d. Using a visual analog scale (VAS)

Answer 42

d. Using a visual analog scale (VAS)
Explanation: A VAS is a commonly used tool to assess pain level in patients with Peyronie’s disease.

Question 43

According to the AUA guideline, which of the following oral therapies should not be offered to patients with Peyronie’s disease?
A. Vitamin C
B. Vitamin E
C. Omega-6 fatty acids
D. Procarbazine

Answer 43

B. Vitamin E

Explanation: According to Guideline Statement 6, clinicians should not offer oral therapy with vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or a combination of vitamin E with L-carnitine.

Question 44

Why does the AUA guideline recommend against the use of oral therapies like vitamin E, tamoxifen, procarbazine, and omega-3 fatty acids in the treatment of Peyronie’s disease?

Answer 44

According to Guideline Statement 6, the use of these therapies without efficacy, even in the absence of significant adverse events, constitutes a moderate risk/burden in terms of postponing or preempting the use of other efficacious treatments, the inability to alleviate patient distress, the time expended on treatments that do not work, and the costs associated with these medications or substances. In other words, there is little evidence to support the use of these therapies in the treatment of Peyronie’s disease, and their use may delay or prevent the use of more effective treatments. The Panel also notes that oral therapies are not appropriate for patients with stable disease.

Question 45

What are the seven studies that reported on the effects of Vitamin E in the treatment of Peyronie’s disease, and what were their findings?

Answer 45

The seven studies are Safarinejad 2007, Inal 2006, Pryor & Farrell 1983, Claro 2004, and three additional studies that were not specified in the guideline. The findings varied among the studies, but overall, there was no compelling evidence that vitamin E reduces curvature, plaque, or pain. The RCT reported that the vitamin E and placebo groups had similar curvature and plaque increases, and similar percentages of patients reported improvement or worsening in the vitamin E and placebo groups with nearly two-thirds of patients with worsened curvature in both groups. The observational study reported minimal curvature and plaque decreases, but Inal (2006) reported that curvature and plaque, on average, increased. In terms of pain, the vitamin E and placebo groups improved similarly, and there was no significant difference between the vitamin E group and the placebo group in terms of pain relief.

Question 46

What is the guideline statement regarding the use of electromotive therapy with verapamil in Peyronie’s disease?
a) Clinicians should offer it as a first-line treatment.
b) Clinicians should offer it as a second-line treatment.
c) Clinicians should not offer it.
d) Clinicians should offer it only in certain cases.

Answer 46

c) Clinicians should not offer electromotive therapy with verapamil.

Explanation: The guideline statement clearly mentions that clinicians should not offer this treatment for Peyronie’s disease.

Question 47

What is the main therapy for curvature in patients with Peyronie’s disease?
a. Surgery
b. Intralesional collagenase alone
c. Intralesional collagenase in combination with modeling by the clinician and patient
d. Medications for erectile dysfunction

Answer 47

c. Intralesional collagenase in combination with modeling by the clinician and patient.

Question 48

What is the recommended range of penile curvature for the use of intralesional collagenase?
a. <30 degrees
b. >90 degrees
c. Between 30 and 90 degrees
d. Any degree of curvature

Answer 48

c. Between 30 and 90 degrees.

Question 49

What is the evidence strength grade for the use of intralesional collagenase in combination with modeling for the reduction of penile curvature in patients with Peyronie’s disease?
a. Grade A
b. Grade B
c. Grade C
d. Grade D

Question 50

What are the inclusion and exclusion criteria for the use of intralesional collagenase in combination with modeling for the reduction of penile curvature in patients with Peyronie’s disease? What are the potential adverse events associated with this treatment, and how should clinicians counsel patients regarding the expected treatment effect?

Answer 50

The use of intralesional collagenase in combination with modeling is appropriate only in patients with stable Peyronie’s disease, a penile curvature between 30 and 90 degrees, and intact erectile function with or without the use of medications. The treatment has not been evaluated in patients with hourglass deformity, ventral curvature, calcified plaque, or plaque located proximal to the base of the penis, and outcomes for these subgroups are unknown. The therapy is for curvature and does not treat pain or erectile dysfunction. Patients should be thoroughly counseled regarding the expected average curvature reduction of 17 degrees. Clinicians should be aware that the magnitude of treatment effect beyond placebo is modest, with an average difference of 7.7 degrees between the collagenase and placebo groups. The treatment effect should be considered carefully in the context of potential adverse events, some of which can be serious, such as corporal rupture, penile hematoma, and penile fracture. The Panel notes that the provision of collagenase is contingent on completion of a certification procedure provided by the manufacturer.

Question 51

What is the primary adverse event associated with the use of intralesional collagenase in the treatment of Peyronie’s disease?
A. Penile swelling
B. Penile ecchymosis
C. Penile pain
D. Corporal rupture

Answer 51

B. Penile ecchymosis

Question 52

What percentage of patients in the IMPRESS I and II trials experienced at least one adverse event after up to 4 treatment cycles with collagenase?
A. 84.2%
B. 36.3%
C. 50%
D. 70%

Answer 52

A. 84.2%

Question 53

What are the potential adverse events associated with the use of intralesional collagenase in the treatment of Peyronie’s disease, and how common are they?

Answer 53

The most common adverse events associated with the use of intralesional collagenase in the treatment of Peyronie’s disease are penile ecchymosis (80%), penile swelling (55%), and penile pain (45.4%). Additional adverse events reported in <5% of collagenase-treated patients were blood blister, penile blister, erythema, general pruritus, painful erection, ED, skin discoloration, procedural pain, injection site vesicles, localized edema, dyspareunia, injection site pruritus, nodule, and suprapubic pain. In the IMPRESS I and II trials, 84.2% of patients in the collagenase groups and 36.3% of patients in the placebo groups experienced at least one adverse event after up to 4 treatment cycles. Most adverse events were considered mild or moderate by the investigators and resolved without intervention.

Question 54

What are the patient inclusion criteria and dosing regimens for intralesional interferon α-2b in the treatment of Peyronie’s disease, and what outcomes can be expected?

Answer 54

Based on the RCT inclusion and exclusion criteria, the use of intralesional interferon is appropriate in the patient with stable disease with curvature > 30 degrees and without calcified plaque. Patients should be administered 5 MU interferon α-2b every 2 weeks for 12 weeks (total of 6 injections). Thorough counseling should be given to patients regarding the expected average curvature reduction of 13.5 degrees. The treatment effect beyond placebo is modest, with an average difference of 9 degrees. However, improvements in other PD outcomes such as plaque size, pain, and vascular outcomes have been observed. Therefore, clinicians should bear in mind that the treatment effect is modest but still significant.

Question 55

What potential adverse events should clinicians counsel patients about before beginning treatment with intralesional interferon α-2b?
A) Sinusitis, flu-like symptoms, and minor penile swelling
B) Kidney failure, heart attack, and stroke
C) Blindness, deafness, and paralysis
D) None of the above

Answer 55

A) Clinicians should counsel patients about potential adverse events, including sinusitis, flu-like symptoms, and minor penile swelling before beginning treatment with intralesional interferon α-2b.

Question 56

What is intralesional interferon α-2b and how does it treat Peyronie’s disease?

Answer 56

Intralesional interferon α-2b is a type of medication that is injected directly into the scar tissue in the penis. It works by reducing inflammation and promoting the growth of healthy tissue.

Question 57

What are the potential adverse events associated with treatment with intralesional interferon α-2b?

Answer 57

Patients who receive intralesional interferon α-2b may experience sinusitis, flu-like symptoms of fever, chills, and arthralgia, and minor penile swelling with ecchymosis. These symptoms are typically mild and can be effectively treated with over-the-counter nonsteroidal anti-inflammatory medications. They typically do not last longer than 48 hours. Clinicians should counsel patients about these potential adverse events before beginning treatment with intralesional interferon α-2b.

Question 58

What is the evidence for the use of intralesional verapamil in the treatment of Peyronie’s disease, and what are the concerns related to its use?

Answer 58

The evidence for the use of intralesional verapamil in the treatment of Peyronie’s disease is weak. The available literature is challenging to interpret due to varied patient inclusion criteria, treatment protocols, and conflicting findings. While some studies have reported significant decreases in plaque length, width, and volume, others have reported only small curvature decreases and mixed findings with regard to plaque. Most studies have evaluated combination treatments, making definitive interpretation difficult. Additionally, most studies have focused on patients in the acute phase with dynamic and evolving symptoms, making it difficult to control for Peyronie’s disease’s natural history and for placebo effects. Therefore, the overall balance between benefits and risks/burdens of intralesional verapamil remains unclear. Clinicians who consider the use of intralesional verapamil should be aware of the lack of control for Peyronie’s disease natural history and the substantial uncertainty regarding its efficacy.

Question 59

What are the potential adverse events associated with intralesional verapamil treatment for Peyronie’s disease? Provide examples of the range of minor adverse events reported in studies evaluating this treatment.

Answer 59

According to Guideline Statement 13, potential adverse events associated with intralesional verapamil treatment for Peyronie’s disease include penile bruising, dizziness, nausea, pain at the injection site, loss of libido, weakness, transient pain at the injection site, and sweating. Studies evaluating this treatment have reported a range of minor adverse events, including penile bruising in 15% to 66% of patients, dizziness or nausea in 2% to 10% of patients, loss of libido in 10% of patients, weakness in 16.7% of patients, transient pain at the injection site in 2% of patients, and sweating in 23.3% of patients. It is important for clinicians to counsel patients about the possibility of these adverse events prior to beginning treatment with intralesional verapamil.

Question 60

What is the recommended guideline statement for the use of extracorporeal shock wave therapy (ESWT) in reducing penile curvature or plaque size in Peyronie’s disease?
a. Clinicians should use ESWT for the reduction of penile curvature or plaque size.
b. Clinicians should not use ESWT for the reduction of penile curvature or plaque size.
c. ESWT is not effective in reducing penile curvature or plaque size in Peyronie’s disease.
d. ESWT is only recommended in certain types of Peyronie’s disease.

Answer 60

b. Clinicians should not use ESWT for the reduction of penile curvature or plaque size.

Explanation: Guideline Statement 14 recommends that clinicians should not use ESWT for the reduction of penile curvature or plaque size in Peyronie’s disease.

Question 61

What is the primary symptom that ESWT may improve in PD patients?
A) Erectile dysfunction
B) Penile curvature
C) Penile pain
D) Peyronie’s plaques

Answer 61

C) Penile pain

Explanation: According to the guideline statement, clinicians may offer extracorporeal shock wave therapy (ESWT) to improve penile pain in PD patients.

Question 62

What percentage of ESWT patients with pain reported decreases in pain compared to the placebo/sham group?
A) 48%
B) 65%
C) 75%
D) 85%

Answer 62

D) 85%

Explanation: Hatzichristodoulou (2013) reported that 85% of ESWT patients with pain reported decreases compared to 48% of the placebo/sham group.

Question 63

What adverse events are commonly associated with ESWT?
A) Erectile dysfunction and penile curvature
B) Petechial bleeding or bruising, urethral bleeding or transient hematuria, and minor ecchymosis
C) Peyronie’s plaques and penile pain
D) Headaches and nausea

Answer 63

B) Petechial bleeding or bruising, urethral bleeding or transient hematuria, and minor ecchymosis

Explanation: ESWT is associated with frequent adverse events, including localized petechial bleeding or bruising, urethral bleeding or transient hematuria, and minor ecchymosis. Severe adverse events are infrequent, but the most common severe adverse event is pain.

Question 64

Why is the guideline statement for ESWT to improve penile pain conditional?
A) Pain is the PD symptom that is most likely to resolve over time without intervention.
B) ESWT is not effective at alleviating pain in PD patients.
C) ESWT is associated with frequent adverse events.
D) Other treatments may be equally effective at alleviating pain.

Answer 64

A) Pain is the PD symptom that is most likely to resolve over time without intervention.

Explanation: The guideline statement for ESWT to improve penile pain is conditional because pain is the PD symptom that is most likely to resolve over time without intervention, the patient burden involved in obtaining ESWT treatment to treat pain may be substantial, and other treatments may be equally effective at alleviating pain. Additionally, ESWT is associated with frequent adverse events, which must be weighed against the potential benefit of pain relief.

Question 65

According to Guideline Statement 16, should clinicians use radiotherapy (RT) to treat Peyronie’s Disease?
A) Yes, it is a highly effective treatment option.
B) No, it is not recommended due to potential risks and uncertain benefits.
C) It can be used in certain cases, depending on the severity of the disease.
D) It is recommended only as a last resort when other treatment options have failed.

Answer 65

B) No, it is not recommended due to potential risks and uncertain benefits.

Question 66

What are the limitations of the observational studies that evaluated the use of radiotherapy (RT) to treat Peyronie’s Disease, as discussed in Guideline Statement 16?

Answer 66

The observational studies evaluating the use of RT to treat PD have several limitations. Firstly, they used a wide range of RT doses, which makes it difficult to draw meaningful conclusions about the efficacy of the treatment. Secondly, most studies had single group designs, which means there was no comparison group for assessing the efficacy of the treatment. Thirdly, the inclusion criteria for the studies were minimally reported, which makes it difficult to assess whether the patients had a consistent diagnosis of PD.

In addition, the studies relied on subjective patient impressions of curvature and plaque changes, which are known to be poorly correlated with objective measures. Finally, the studies did not use rigorous measurement protocols to assess changes in symptoms over time, which makes it difficult to determine whether the observed changes were due to the passage of time or the treatment itself.

Given these limitations, the Panel interpreted the data to mean that RT should not be offered to patients with PD, as the potential risks of exposing patients to RT in the context of unproven benefits outweigh any potential benefits of the treatment.

Question 67

What is the most common inclusion criteria for surgical studies on Peyronie’s disease?
a. Stable disease for at least 6 months
b. Stable disease for at least 3 months
c. Stable disease for at least 12 months
d. Active disease for at least 3 months

Answer 67

c. Stable disease for at least 12 months.

Patients who are considering surgical
reconstruction as a treatment for PD should be in the
stable phase of the disease. Typically, PD lesions
become stable at 12 to 18 months after symptom
onset. The most common inclusion criteria for surgical
studies are the presence of PD symptoms for at least
12 months and stable curvature for 3 to 6 months.

Question 68

Table 2 - Adverse Events in Surgical Plication Studies

Answer 68

Question 69

What is the most common surgical strategy used to treat Peyronie’s disease?
a. Prosthesis surgery
b. Grafting
c. Tunical plication surgery
d. Vacuum device therapy

Answer 69

c. Tunical plication surgery

Explanation: According to Guideline Statement 18, tunical plication surgery is the most common surgical strategy used to treat Peyronie’s disease, representing approximately half of all surgeries conducted on PD patients.

Question 70

What is the main benefit of tunical plication surgery for Peyronie’s disease?
a. Improvement of penile curvature
b. Improvement of erectile function
c. Increase of penile length
d. None of the above

Answer 70

a. Improvement of penile curvature

Explanation: According to Guideline Statement 18, clinicians may offer tunical plication surgery to patients whose rigidity is adequate for coitus to improve penile curvature.

Question 71

What is the most appropriate candidate for tunical plication surgery?
a. Patients with intact erectile function
b. Patients with ED unresponsive to oral medications
c. Patients with ED unresponsive to vacuum pump therapy
d. Patients with ED unresponsive to ICI therapy

Answer 71

a. Patients with intact erectile function or with ED responsive to oral medications or vacuum pump therapy or ICI therapy.

Explanation: According to the panel’s interpretation of the data, the most appropriate candidates for tunical plication surgery are patients with intact erectile function or with ED responsive to oral medications or vacuum pump therapy or ICI therapy, as plication surgery is not a treatment for ED, and the consequences of plication surgery with regard to erectile function remain unclear.

Question 72

What is the second most common surgical strategy used to treat Peyronie’s Disease (PD) patients?
A. Prosthesis surgery
B. Plaque excision without grafting
C. Plaque incision and/or excision with grafting
D. Plication alone

Answer 72

C. Plaque incision and/or excision with grafting is the second most common surgical strategy used to treat PD patients.

Question 73

What is the range of improvement rates in curvature reported in studies on plaque incision and/or excision with grafting?
A. 0% to 25%
B. 25% to 100%
C. 50% to 75%
D. 75% to 100%

Answer 73

B. Improvement rates ranged from 25% to 100% in the studies reported, with most reporting rates >80% and some reporting rates >90%.

Question 74

What factors should be considered when selecting appropriate candidates for plaque incision and/or excision with grafting in the treatment of Peyronie’s Disease?

Answer 74

The most appropriate candidates for plaque incision and/or excision with grafting are patients with intact erectile function or with ED responsive to oral medications or vacuum pump therapy. This is because these surgical strategies are not treatments for ED, and the consequences of surgery with regard to erectile function remain unclear. Additionally, the range of patient inclusion criteria, the variations in surgical techniques performed, and the range of follow-up durations make the body of evidence strength Grade C. However, the recommendation for plaque incision and/or excision with grafting is Moderate given the clear benefit of surgery to ameliorate curvature in most patients in the setting of relatively few serious adverse events.

Question 75

What is the recommended treatment for patients with Peyronie’s Disease and erectile dysfunction and/or penile deformity sufficient to impair coitus despite pharmacotherapy and/or vacuum device therapy?
a) Surgery
b) Medication
c) Physical therapy
d) Psychotherapy

Answer 75

a) Surgery

Explanation: According to Guideline Statement 20, clinicians may offer penile prosthesis surgery to patients with Peyronie’s Disease and erectile dysfunction and/or penile deformity sufficient to impair coitus despite pharmacotherapy and/or vacuum device therapy.

Question 76

What are some of the intra-operative procedures that may be performed to address significant penile deformity after insertion of a penile prosthesis?
a. Chemotherapy
b. Radiation therapy
c. Modeling, plication, or incision/grafting
d. Antibiotic administration

Answer 76

c. Intra-operative procedures such as modeling, plication, or incision/grafting may be performed to address significant penile deformity after insertion of a penile prosthesis.

Question 77

What type of penile prosthesis is recommended for patients undergoing penile prosthetic surgery for Peyronie’s disease?
a. Semi-rigid prostheses
b. Inflatable prostheses containing reinforced silicone or bioflex® material
c. Non-inflatable prostheses
d. Non-reinforced silicone inflatable prostheses

Answer 77

b. Inflatable prostheses containing reinforced silicone or bioflex® material are recommended for patients undergoing penile prosthetic surgery for Peyronie’s disease.

Question 78

What are the potential complications of penile prosthetic surgery for Peyronie’s disease?

Answer 78

Complications of penile prosthetic surgery for Peyronie’s disease include infection, mechanical failure of the prosthesis, erosion or extrusion of the prosthesis, and persistent penile curvature or deformity. However, inflatable prostheses containing reinforced silicone or bioflex® material are associated with fewer adverse events and higher patient satisfaction rates.

Question 79

What is the evidence base for the use of colchicine in the treatment of Peyronie’s Disease, and why is the evidence considered unproven?

Answer 79

Five studies have evaluated the effects of colchicine either alone or in combination with another oral treatment. Although studies generally reported that large proportions of patients exhibited improvements in curvature, plaque, and pain, without controls for the natural history of PD these data remain of uncertain utility. Therefore, the evidence base for the use of colchicine in the treatment of Peyronie’s Disease is considered unproven until a larger and/or more rigorous evidence base is available.

Question 80

What is Pentoxifylline?
A) A type of surgical procedure for Peyronie’s Disease
B) An oral medication for Peyronie’s Disease
C) A topical ointment for Peyronie’s Disease
D) A device used for Peyronie’s Disease

Answer 80

B) An oral medication for Peyronie’s Disease

Question 81

What does the Alizadeh (2014) study compare Pentoxifylline to?
A) A placebo control group
B) A surgical procedure
C) Intralesional Verapamil
D) A topical ointment

Answer 81

C) Intralesional Verapamil

Question 82

What is the limitation of the Alizadeh (2014) study?
A) It lacks a control for PD natural history
B) It only includes proportion data
C) It did not use a randomized design
D) All of the above

Answer 82

: D) All of the above

Question 83

What is the mechanism of action of Pentoxifylline?

Answer 83

The exact mechanism of action of Pentoxifylline in Peyronie’s Disease is not fully understood. However, it is believed to work by improving blood flow and reducing inflammation. Pentoxifylline is a type of methylxanthine and a non-specific phosphodiesterase inhibitor. It has been shown to increase red blood cell flexibility and reduce blood viscosity, which may improve circulation in the penis. Pentoxifylline is also thought to have anti-inflammatory effects by inhibiting the production of inflammatory cytokines and reducing the activity of white blood cells. These effects may help to reduce the size of the plaque and improve curvature of the penis in Peyronie’s Disease.

Question 84

What is the mechanism of action of colchicine in Peyronie’s?

Answer 84

The mechanism of action of colchicine in Peyronie’s Disease is not completely understood, but it is believed to work by reducing inflammation and preventing the buildup of collagen. Colchicine is an alkaloid that is derived from the autumn crocus plant, and it has been used as a treatment for a variety of inflammatory conditions. In Peyronie’s Disease, colchicine is thought to reduce inflammation by inhibiting the activity of white blood cells and reducing the production of inflammatory cytokines. It is also believed to prevent the buildup of collagen, which is a component of the plaque that forms on the penis in Peyronie’s Disease. Collagen is produced by a type of cell called a fibroblast, and colchicine is thought to inhibit fibroblast activity, which may help to reduce the size of the plaque and improve curvature of the penis. However, the exact mechanism of action of colchicine in Peyronie’s Disease is still being studied and is not completely understood.

Question 85

What did the study find regarding the effect of potassium aminobenzoate on plaque volume?
a) Plaque volume decreased more in the active treatment arm than in the placebo arm.
b) Plaque volume decreased more in the placebo arm than in the active treatment arm.
c) There was no difference in plaque volume between the active and placebo arms.
d) The study did not evaluate the effect of potassium aminobenzoate on plaque volume.

Answer 85

a) Plaque volume decreased more in the active treatment arm than in the placebo arm.

Question 86

What is potassium aminobenzoate and how is it thought to work in treating PD?

Answer 86

Potassium aminobenzoate is a form of the B vitamin PABA (para-aminobenzoic acid) that is believed to improve blood flow to the penis and reduce inflammation in the tissues. It is thought to work by promoting the production of collagen, which can help to break down the scar tissue that causes the curvature in PD.

Question 87

What is Co-enzyme Q10?
A) An enzyme
B) A co-enzyme
C) A vitamin
D) A mineral

Answer 87

B) A co-enzyme

Explanation: Co-enzyme Q10 is a co-enzyme that plays a key role in the production of energy within cells. It is found in every cell in the body and is especially concentrated in the heart, liver, and kidneys.

Question 88

What were the findings of the study on Co-enzyme Q10 and PD?
A) CoQ10 significantly reduced pain but had no effect on curvature or plaque size
B) CoQ10 significantly reduced curvature and plaque size but had no effect on pain
C) CoQ10 significantly reduced both pain and curvature but had no effect on plaque size
D) CoQ10 had no significant effects on pain, curvature, or plaque size

Answer 88

B) CoQ10 significantly reduced curvature and plaque size but had no effect on pain

Explanation: The authors of the RCT reported that CoQ10 significantly reduced curvature and plaque size in the active treatment group compared to the placebo group. However, there were no effects on pain.

Question 89

Do the findings of this study support the use of CoQ10 as a treatment for PD?
A) Yes, the study provides strong evidence that CoQ10 is an effective treatment for PD
B) No, the study provides weak evidence and further research is needed to determine the efficacy of CoQ10 as a PD treatment
C) The study is inconclusive and more research is needed to determine the effects of CoQ10 on PD

Answer 89

B) No, the study provides weak evidence and further research is needed to determine the efficacy of CoQ10 as a PD treatment

Explanation: The authors of the RCT noted that while CoQ10 showed promise in reducing curvature and plaque size, the efficacy of CoQ10 is unproven given the existence of only one study and the fact that <100 patients were administered CoQ10. Replication in a high-quality randomized design is needed before it can be recommended as a PD treatment. Therefore, the study provides weak evidence and further research is needed to determine the efficacy of CoQ10 as a PD treatment.

Question 90

Explain the findings of the RCT evaluating topical magnesium and verapamil for PD treatment and the need for replication in a high-quality randomized design with a larger sample size before recommending verapamil as a PD treatment.

Answer 90

The RCT evaluated the efficacy of topical magnesium and verapamil for PD treatment in comparison to placebo. The results showed that topical verapamil improved curvature and reduced plaque compared to placebo, while the magnesium sulfate group had comparable results to the placebo group. More patients in the verapamil group experienced curvature improvement and plaque reduction compared to the placebo group. However, uncertainty remains regarding the efficacy of topical verapamil as there was only one study conducted and <20 patients were administered verapamil. Therefore, replication in a high-quality randomized design with a larger sample size is necessary before recommending verapamil as a PD treatment.

Question 91

What is topical liposomal recombinant human superoxide dismutase (LrhSOD) and how is it thought to work in the treatment of Peyronie’s disease?

Answer 91

Topical liposomal recombinant human superoxide dismutase (LrhSOD) is a drug that is thought to work by reducing oxidative stress and inflammation in the penis, thereby promoting healing of the fibrous plaques and reducing curvature and pain.

Question 92

What is the effect of topical LrhSOD on pain in patients with Peyronie’s disease?
a) No effect
b) Significant reduction in pain compared to placebo
c) Increase in pain
d) It is unclear

Answer 92

b) Significant reduction in pain compared to placebo

Explanation: According to the two studies mentioned, topical LrhSOD for four weeks significantly reduced pain compared to placebo.

Question 93

What was the percentage of patients who reported plaque improvement in the observational study?
a) 23%
b) 47%
c) 56%
d) 100%

Answer 93

c) 56%

Explanation: The observational study mentioned that 56% of patients reported plaque improvement.

Question 94

What were the findings of the two studies mentioned in the article regarding the efficacy of topical LrhSOD in the treatment of Peyronie’s disease?

Answer 94

The two studies mentioned in the article found that topical LrhSOD for four weeks significantly reduced pain compared to placebo. In the open-label phase of one trial, pain improvement continued and curvature improvements were noted in 23% of patients and plaque reductions in 47% of patients. In the observational study, 25% of patients reported curvature improvement, 56% reported plaque improvement, and 100% reported pain improvement. However, the article notes that the body of evidence is small and replication in a high-quality randomized design with a larger sample size is needed before it can be recommended as a PD treatment.

Question 95

What is electromotive verapamil + dexamethasone?
a) A surgical procedure to treat Peyronie’s disease
b) A medication to treat erectile dysfunction
c) An electromotive therapy for Peyronie’s disease
d) A diagnostic test for urological disorders

Answer 95

c) An electromotive therapy for Peyronie’s disease

Explanation: Electromotive verapamil + dexamethasone is a type of therapy used to treat Peyronie’s disease, a condition where there is an abnormal curvature of the penis due to the development of fibrous scar tissue within the tunica albuginea.

Question 96

What is the difference between electromotive verapamil + dexamethasone and intralesional verapamil + dexamethasone?
a) Electromotive therapy is non-invasive, while intralesional therapy involves injections
b) Electromotive therapy involves higher doses of medication than intralesional therapy
c) Electromotive therapy is less effective than intralesional therapy
d) There is no difference between the two therapies

Answer 96

a) Electromotive therapy is non-invasive, while intralesional therapy involves injections

Explanation: Electromotive therapy involves the use of a small electrical current to facilitate the absorption of verapamil and dexamethasone through the skin and into the tissue of the penis, while intralesional therapy involves injecting the medication directly into the plaque.

Question 97

What were the main findings of the study by Di Stasi (2004)?
a) Electromotive verapamil + dexamethasone was more effective than lidocaine electromotive in reducing plaque volume and penile curvature
b) Electromotive verapamil + dexamethasone was less effective than lidocaine electromotive in reducing plaque volume and penile curvature
c) Lidocaine electromotive was more effective than both intralesional and electromotive verapamil + dexamethasone
d) There were no significant differences between the treatment groups

Answer 97

a) Electromotive verapamil + dexamethasone was more effective than lidocaine electromotive in reducing plaque volume and penile curvature

Explanation: In the study by Di Stasi (2004), electromotive verapamil + dexamethasone was compared to lidocaine electromotive in the treatment of Peyronie’s disease. The results showed that while both treatments improved pain, electromotive verapamil + dexamethasone was more effective in reducing plaque volume and penile curvature.