Page 4 - 2018 Canadian Urological Association guideline for Peyronie’s disease and congenital penile curvature

Bella et al

in response to specific findings on history or physical exami- procarbazine, and vitamin E/L-carnitine are not used in the
nation (for example, signs/symptoms of hypogonadism). 1,3 treatment of PD. Vitamin E, in particular, does not have any
evidence for efficacy. The oral agents potassium para-amino-
Non-surgical management of PD benzoate, colchicine, co-enzyme Q10, and/or pentoxifylline
may be considered for clinical use, alone or as a part of
It is essential to recognize that PD is a symptom complex multimodal care (oral, intralesional, and traction therapies),
that may compromise sexual function and QoL, may affect but there are clear limitations to the evidence; the AUA has
men from early decades of life through their later years, and identified these agents as possibly promising, but with insuf-
does not have a clearly defined management pathway due ficient evidence to support even a conditional recommenda-
to the heterogeneity of the disease itself. tion for use until a larger or more rigorous evidence base
The patient should be aware that not all urologists have the is avaialable. It is the consensus of this panel that these
1,3
training, experience, and resources to conduct full evaluation, oral agents may be offered as part of PD care, recognizing
counsel on various treatment options, and offer care oriented limitations to efficacy data, alone or as part of multimodal
to patient PD and goals. It is entirely appropriate for urologist- care. Care should be taken not to unnecessarily postpone
to-urologist referral, as within the Canadian healthcare context other PD therapies, and limitations to evidence and added
not all regions will maintain PD expertise and a goal such as patient-borne costs of treatment should be clearly commu-
this is elusive, given systemic demands and constraints. nicated (Level 3 evidence, Grade C recommendation). The
use of PDE-5 inhibitors, specifically tadalafil 5 mg OD to
Clinical principle modify Peyronie’s plaque progression appears promising, but
to date, data is limited to a single published study. 25
Clinicians should discuss the various aspects of a potential Current medical literature is replete with several further
treatment plan, including careful weighing of potential ben- agents proposed solely on their efficacy in animal models of
efit to the patient vs. adverse events. As PD does not impact PD, when in fact, there is valid concern that such models are
survival, for some men, thoughtful review and counselling not representative of human PD. Use in a study setting with
regarding their PD, impact on QoL, disease course, and man- full patient consent or in special situations may be justified
agement options may constitute their “treatment,.” As there is on an ad hoc basis, but clearly the evidence is simply not
no minimum criteria for deformity necessary for management, in place for general use.
a patient may decide to seek treatment based on distress over Oral non-steroidal anti-inflammatory medication may be
symptoms, penile appearance, and penile function, which used to control the pain associated with the inflammation dur-
for another would constitute end-of-treatment success or PD ing the active phase of the disease. Penile pain may confer sig-
not requiring any intervention. For most men, deformity less nificant distress and may compromise sexual function; the ideal
than 30 degrees does not impair function; the Committee agent, duration, and re-assessment has not been elucidated. 1,3
supports a clear discussion with the patient of their PD after The treatment of ED concomitant with PD follows CUA
8
evaluation and integration of treatment choices into their care guidelines for the management of erectile dysfunction. Oral
plan, which is consistent with patient symptom status, current PDE-5 inhibitors are used in patients for whom there are
health, and treatment goals. 1,3,23 no medication-specific contraindications; if the degree of
deformity makes penetrative intercourse difficult due to PD
Oral and topical therapies angulation, the patient (and partner) should minimize pain
and potential injury by limiting positions to those allowing
comfortable penetration.
Oral therapy
Topical electromotive therapy (iontophoresis) with verapamil or dexamethasone
There is currently no approved oral treatment of PD in
Canada. The few available trials have not enrolled enough The use of iontophoresis is not recommended. There remains
patients to attain sufficient power, and meta-analysis is dif- an absence of convincing efficacy and a substantial burden
ficult because of the heterogeneity of treatments and duration of administration. The CUA position is consistent with both
of followup, as well as inconsistencies across study endpoints. the recent evaluations by the AUA and the ICSM (Level 4
The following medications have either been shown in evidence, Grade 3 recommendation). 1,3,28,29
studies with low/moderate level of evidence to be without
proven efficacy/limited potential efficacy and may have del- 3. Topical therapy – verapamil gel
eterious side effects.
None of the following oral agents are recommended Uncertain and only potential efficacy is seen with the use
for standard care of PD in Canada: Vitamin E, tamoxifen, of verapamil gel and its use cannot be supported by the

E200 CUAJ • May 2018 • Volume 12, Issue 5