***Trost Commentary and Key Take-Home Points***
The current study evaluates the use of intralesional hyaluronic acid to treat Peyronie’s Disease. This is one of 4 different types of injections which are most commonly reported, with the others being collagenase (Xiaflex), interferon, and verapamil. This specific injection is more commonly used in Europe, particularly now that collagenase is no longer available for injection throughout Europe. The authors in this study reported improvements in penile curvature (10 degrees), plaque size (2 mm), and results on Peyronie’s questionnaires. The main issue with studies such as this is that they lack a control group (where people received injections without hyaluronic acid). Historically, studies which have used a control group like this have shown similar results in the control arm (meaning that this treatment likely didn’t actually do much, if anything). Similarly, a meta-analysis of studies comparing the 4 major injectables showed that verapamil and hyaluronic acid did the worst in general, while interferon and collagenase did the best. So, the key take home message regarding any injectables is that for treating curvature, collagenase is the best that we have available, followed by interferon. Verapamil and hyaluronic acid probably don’t have any true role in the management of Peyronie’s Disease, based on the best currently available evidence.
Peyronie’s disease is a fibrotic condition characterized by the formation of penile plaques in the tunica albuginea and affects between 3.2% – 8.9% of men. The plaques cause penile curvature, deformity, pain, erectile dysfunction, sexual satisfaction and psychological issues. The pathophysiology and etiology are unknown, though penile trauma or microtraumas are thought to play a role.
Current treatments include surgery or more conservative options such as oral pharmacotherapy, intralesional injections or topical treatments. The current suggested treatment from the American Association of Urology is intralesional injection of clostridium histolyticum collagenase (CHC), though it is associated with several mild to severe adverse events and high cost.
Hyaluronic acid has effectively been used in cosmetic surgery and orthopedics to decrease scar formation and stop or reduce the effects of inflammation and oxidative stress from certain substances. This study seeks to assess the effects of hyaluronic acid on penile plaque size, curvature and sexual satisfaction in Peyronie’s disease patients.
This study included men with Peyronie’s disease with a penile plaque and penile pain without calcification of plaques or hourglass deformity and no previous oral or injection treatments for Peyronie’s disease. Patients participating in the study were fully evaluated and consented prior to treatment and stratified into 6 curvature categories: 0-10 degrees, 10-20 degrees, 20-30 degrees, 30-40 degrees, 40-50 degrees, and >50 degrees.
This study consisted of 65 eligible men who were treated with hyaluronic acid weekly for 10 weeks. The patients had a median age of 57 years, median plaque size of 10 mm, median curvature of 30 degrees and 55% had mild to moderate erectile dysfunction.
After 10 hyaluronic injections, plaque size decreased by a mean 2mm in 57% of patients, curvature improved by 10 degrees, and erectile dysfunction decreased from 55% to 40%.
Hyaluronic acid is commonly used in the treatment of osteoarthritis of the knee where it reduces oxygen-free radicals in the synovial fluid, inhibits apoptosis, promotes cell survival and decreases concentrations of inflammatory proteins. There are the same cells at play with Peyronie’s disease leading to a hypothesis that hyaluronic acid could be similarly successful in this population.
Most treatments are focused on patients in the chronic phase of the disease, though some success has been seen with intralesional injections of verapamil, interferon and corticosteroids during the acute phase of Peyronie’s disease.
Hyaluronic acid results in fewer and more minor adverse events than CHC and other injection therapies and was effective in decreasing plaque size and curvature and increasing sexual satisfaction.
Hyaluronic acid is a promising therapy option with preliminary data showing improvements in plaque size, penile curvature, and sexual satisfaction with limited adverse events during the acute phase of the disease. Larger, rigorous studies are needed to verify these results.
Zucchi A, Costantini E, Cai T, Cavallini G, Liguori G, Favilla V, De Grande G, D’Achille G, Silvani M, Franco G, Palmieri A, Verze P, Mirone V. Intralesional Injection of Hyaluronic Acid in Patients Affected With Peyronie’s Disease: Preliminary Results From a Prospective, Multicenter, Pilot Study. Sex Med. 2016 Jun;4(2):e83-8. doi: 10.1016/j.esxm.2016.01.002. Epub 2016 Mar 13. PMID: 26984291; PMCID: PMC5005307.