Evidence-Based Management Guidelines on Peyronie's Disease

The CUA endorses a good home photograph with protractor measurement as a less accurate alternative for curvature evaluation.

“The CUA endorses the use of an adequate home photograph with protractor-estimate of penile angulation as an alternative (less accurate) approach to evaluate curvature.28”

The EAU and ISSM guidelines list medical conditions associated with PD, including Dupuytren's contracture, diabetes, hypertension, lipid disease, ischemic cardiomyopathy, ED, low testosterone, pelvic surgery, and tobacco or alcohol use.

“EAU and ISSM guidelines describe specific medical comorbidities that have been associated with PD such as Dupuytren’s contracture, diabetes, hypertension, lipid disease, ischemic cardiomyopathy, ED, low testosterone, pelvic surgery, as well as tobacco and alcohol use.28, 29”

AUA and ISSM recommend ICI but suggest home photography may be sufficient in some cases.

“The AUA and ISSM guideline panels recommend ICI, but hedge by suggesting that home photography may be “sufficient” in some cases.1, 28”

Guidelines differ on how many months after symptom onset define stable disease, from six months in CUA and ISSM to more than 12 months in AUA.

“In contrast, there is discrepancy regarding the number of months since symptom onset that defines stable disease, ranging from six-months (CUA, ISSM) to greater than 12-months (AUA).1, 26, 28”

A careful history and physical examination is required and may be enough for diagnosis, according to expert opinion from AUA, CUA, and ISSM.

“A careful history and physical examination is mandated and may be all that is needed to make the diagnosis based on expert opinion from the AUA, CUA, and ISSM panels.1, 26, 28”

The AUA, ISSM, CUA, and EAU each issued a PD clinical guideline in the five years before this review.

“Within the last five years clinical guidelines were published by the American Urological Association (AUA), International Society for Sexual Medicine (ISSM), Canadian Urological Association (CUA), and the European Association of Urology (EAU).26–29”

The ISSM guideline stresses that grafting surgeries should be done by experts.

“Specifically citing the complexity of grafting surgeries, ISSM again emphasizes that these should be performed by experts.28”

No guideline requires routine use of these questionnaires, but ISSM specifically emphasizes PDQ for baseline data and monitoring treatment outcomes.

“No guideline mandates the routine use of these questionnaires, although the ISSM guideline panel explicitly emphasizes the PDQ to establish baseline data and monitor treatment outcomes.28”

The ISSM underscores lack of proven benefit for iontophoresis and suggests that curvature decrease in some series may be due to energy delivered to tissue.

“the ISSM guideline panel underscores the lack of proven benefit and suggests that the decrease in curvature seen in some series may be due to the energy delivered to the tissue.”

All panels acknowledge these psychosocial concerns and stress assessing psychological burden with subjective and objective measures, including the PDQ symptom-bother domain.

“These concerns are acknowledged by all guideline panels with emphasis placed on assessing psychological burden through subjective and objective measures, including the PDQ which has a specific domain pertaining to symptom bother.1, 26, 28, 29”

The ISSM does not recommend any oral therapy as primary treatment for Peyronie's disease because of lack of proven benefit in rigorous clinical studies.

“The ISSM guideline does not recommend any oral therapy as primary treatment due to the lack of proven benefit in rigorous clinical studies to date.”

The ISSM guideline group aligns with the AUA recommendations on mechanical therapies.

“This is line with recommendations by the ISSM guideline group as well.”

The ISSM guideline describes a similar stance on intralesional verapamil.

“A similar stance is described within the ISSM guideline.”

The EAU, AUA, and CUA emphasize lack of robust evidence for hyaluronic acid and botulinum toxin therapy in Peyronie's disease.

“The EAU, AUA, and CUA also emphasize the lack of robust evidence to support hyaluronic acid and botulinum toxin therapy for PD.”

CUA, EAU, and ISSM discourage MRI, CT, and plain-film X-ray because they lack proven efficacy and involve expense and radiation.

“Other imaging modalities including MRI, CT, and plain-film XRAY are discouraged by the CUA, EAU, and ISSM guideline panels given their lack of proven efficacy, expense, and radiation exposure.26, 28”

AUA, CUA, and ISSM support PD/PDDU as optional for evaluating plaque characteristics and penile hemodynamics.

“In contrast, AUA, CUA, and ISSM guideline panels support PD/PDDU as optional to evaluate plaque characteristics and penile hemodynamics.126, 28”

The CUA, EAU, and ISSM suggest plaque incision with grafting be reserved for men with more severe penile deformity.

“The CUA, EAU, and ISSM guideline panels suggest that plaque incision with grafting be reserved for men with more severe penile deformity.”

The ISSM and recent EAU guidelines outline similar algorithms for adjunctive procedures with inflatable penile prosthesis placement, based on this and other earlier publications.

“ISSM and the recent EAU guidelines both outline similar algorithms for the adjunctive procedures often employed with IPP placement, based on this and other earlier publications.”

The CUA and ISSM consider isolated hourglass deformity and severe plaque calcification as exclusion criteria for collagenase clostridium histolyticum.

“The CUA and ISSM guideline panels consider isolated hourglass deformity and severe plaque calcification as exclusion criteria for CCH.”

The ISSM recommends grafting over the defect if a defect greater than 2 cm results.

“Per the ISSM guideline, grafting over the defect is recommended if a defect >2 cm results.”

The CUA, EAU, and ISSM strongly recommend against synthetic grafts because of adverse outcomes including persistent or recurrent fibrosis and infection.

“The CUA, EAU, and ISSM panels recommend strongly against synthetic grafts as they have been associated with adverse outcomes including persistent/recurrent fibrosis and infection.”

The EAU, CUA, and ISSM emphasize the concept of a functionally straight penis, within 20 degrees of straight rather than arrow straight.

“The EAU, CUA, and ISSM panels specifically emphasize the concept of a “functionally” straight penis (i.e. within 20o of straight as opposed to “arrow” straight).”

The ISSM suggests stable Peyronie's disease symptoms for at least 6 months before surgery, while the AUA indicates symptom duration of at least 12 months with 3 to 6 months of symptom stability.

“the ISSM panel suggests that patients should have stable PD symptoms for at least 6 months prior to surgery as compared to the AUA which indicates symptom duration of at least 12 months with 3–6 months of symptom stability.”

The ISSM highlights traction combined with PDE5 inhibitors as an option for penile rehabilitation.

“ISSM also highlights traction in combination with PDE-5i as an option for penile rehabilitation.”

The PDQ is considered an adjunctive evaluation tool by the CUA and ISSM, and the EAU recommends it during initial assessment and follow-up to determine treatment efficacy beyond objective measurements.

“The PDQ is considered an adjunctive evaluation tool by the CUA and ISSM, and the EAU now recommends this tool during the initial assessment and subsequent follow-up to determine treatment efficacy beyond simple objective measurements.”