Management of Peyronie's Disease with Collagenase Clostridium Histolyticum in the Acute Phase

Peyronie’s disease (PD) is a pathology that causes penile pain, curvature, and erectile dysfunction. This trifecta almost guarantees frustration in men, hence saving time and treating PD as early as possible is crucial. PD is divided into two distinct phases: acute and chronic. The ability to differentiate both phases is important, as treatment can be different between the two. The transition from the acute to the chronic phase is established when the deformity is no longer progressive or unchanged for at least 3 months and when pain with or without erection becomes less common. The only injectable agent that is Food and Drug Administration approved in the chronic phase is collagenase clostridium histolyticum (CCH), and its use in the acute phase is off label. Only a few limited studies have evaluated its potential benefits during the acute phase and, as such, we opted to perform a PubMed database search for recent articles that investigated the use of CCH for the management of the acute phase of PD in order to evaluate both its efficacy and safety.

Delaying treatment until the chronic phase is established can be disappointing for patients as the acute phase can last up to 18 months. Being unable to engage in sexual intercourse for such a long period of time can be depressing and can have a negative impact on relationships, and even in society, as men suffering from depression are less productive. No consensus exists on the ideal time to initiate intralesional CCH treatment but owing to the significant distress associated with PD and the lack of efficacious therapies in the acute phase, several studies used CCH as an off-label treatment for the management of PD in the acute phase. Combining the four studies included in this review, four treatment cycles over a six weeks period was the mainstream management protocol. Results showed a mean curvature improvement ranging from 15.8° to 22.6° corresponding to a 27.4-37.4% decrease of curvature from baseline. It is important to mention that in the IMPRESS trials there was a 34% improvement in curvature in patients in the chronic phase of the disease. Similarities in the degree of curvature improvement observed using CCH injections in the acute and chronic phases may eventually lead to a wider and more inclusive label change.

Although larger multi-institutional studies are still needed to confirm the findings in this review and validate this additional indication for CCH, results using intralesional CCH injection therapy during the acute phase of PD are promising, as they demonstrate safety, clinical efficacy.

Written by: Farouk M. El-Khatib, MD, Mahdi Osman, MD, Linda M. Huynh, MD, Faysal A. Yafi, MD, Department of Urology, University of California Irvine, California, United States

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