Peyronie's Disease

Question 1

Which of the following statements is true about the non-surgical management of Peyronie’s Disease (PD)?
A. PD affects only men in their later years.
B. PD has a clearly defined management pathway.
C. Deformity less than 30 degrees usually impairs function.
D. PD is a symptom complex that can affect quality of life.

Answer 1

Answer: D
Peyronie’s Disease (PD) is not solely age-dependent and can affect men at different ages. Its management isn’t always straightforward, and deformity less than 30 degrees usually does not impair function. Thus, PD mainly affects the quality of life of those who suffer from it.

Question 2

Which of the following oral agents is approved for the standard care of PD in Canada?
A. Vitamin E
B. Tamoxifen
C. Procarbazine
D. None of the above

Answer 2

Answer: D
No oral agents are approved for the standard care of PD in Canada. Both vitamin E and Tamoxifen have been tried, but neither has shown consistent efficacy in clinical trials.

Question 3

What level of evidence supports the use of PDE-5 inhibitors like tadalafil for modifying Peyronie’s plaque progression?
A. Level 1
B. Level 2
C. Level 3
D. Limited to a single published study

Answer 3

Answer: D
The evidence supporting the use of PDE-5 inhibitors for modifying plaque progression in PD is limited to a single published study.

Question 4

What is the CUA’s position on the use of iontophoresis in PD?
A. Strongly recommended
B. Recommended
C. Not recommended
D. Conditional recommendation

Answer 4

Answer: C
The CUA does not recommend iontophoresis for the treatment of PD, given the lack of convincing evidence.

Question 5

In terms of intralesional therapies, what is considered as first-line therapy according to the CUA?
A. Verapamil
B. Interferon
C. Collagenase (Xiaflex)
D. Vitamin E

Answer 5

Answer: C
Collagenase (Xiaflex) is considered the first-line intralesional therapy, according to CUA guidelines.

Question 6

What is the Grade of recommendation for using clostridial collagenase in the management of PD in Canada?
A. Grade A
B. Grade B
C. Grade C
D. Grade D

Answer 6

Answer: B
The grade of recommendation for using clostridial collagenase in the management of PD in Canada is Grade B.

Question 7

For which of the following deformities has the use of intralesional collagenase not been evaluated?
A. Curvature greater than 90°
B. Isolated hourglass deformity
C. Curvature less than 30°
D. All of the above

Answer 7

Answer: D
The use of intralesional collagenase has not been evaluated for curvature greater than 90°, isolated hourglass deformity, or curvature less than 30°.

Question 8

What is a common side effect of intralesional verapamil (ILV)?
A. Penile bruising
B. Myocardial infarction
C. Systemic toxicity
D. Renal failure

Answer 8

Answer: A
A common side effect of intralesional verapamil is penile bruising, not myocardial infarction or systemic toxicity.

Question 9

Which topical therapy has uncertain and only potential efficacy for PD according to the CUA?
A. Iontophoresis with verapamil
B. Dexamethasone gel
C. Verapamil gel
D. Topical Vitamin E

Answer 9

Answer: C
The CUA indicates that the efficacy of verapamil gel in the treatment of PD is uncertain.

Question 10

Which of the following factors can be a predictor of efficacy in ILV treatment for PD?
A. Older age
B. Smaller baseline curvature
C. Higher dilutions of verapamil
D. Larger plaques

Answer 10

Answer: B
Smaller baseline curvature can be a predictor of efficacy in intralesional verapamil treatment for PD.

Question 11

What type of agents does clostridial collagenase belong to?
A. Prostaglandins
B. Collagenases
C. Calcium-channel blockers
D. PDE-5 inhibitors

Answer 11

Answer: B
Clostridial collagenase belongs to the group of collagenases.

Question 12

What is a significant limitation to the evidence for using oral agents in PD?
A. Lack of long-term follow-up studies
B. Heterogeneity of treatments and duration of follow-up
C. Small sample size
D. All of the above

Answer 12

Answer: D
All the options (Lack of long-term follow-up studies, Heterogeneity of treatments, and Small sample size) represent limitations to the evidence for using oral agents in PD.

Question 13

How does the CUA recommend managing pain in the active phase of PD?
A. Oral non-steroidal anti-inflammatory medication
B. Opioid analgesics
C. Aspirin
D. No recommendation exists

Answer 13

Answer: D
The CUA guidelines do not provide a specific recommendation for managing pain in the active phase of PD.

Question 14

According to the CUA, at what point should a patient seek treatment for PD based on deformity?
A. Only if deformity is more than 60 degrees
B. Only if deformity is more than 30 degrees
C. There is no minimum criteria for deformity necessary for management
D. Deformity less than 30 degrees is a contraindication for treatment

Answer 14

Answer: C
The CUA guidelines do not specify a minimum degree of deformity for a patient to seek treatment for PD.

Question 15

What level of evidence and grade of recommendation does the use of iontophoresis have, according to the CUA?
A. Level 2 evidence, Grade A recommendation
B. Level 3 evidence, Grade C recommendation
C. Level 4 evidence, Grade 3 recommendation
D. Level 1 evidence, Grade D recommendation

Answer 15

Answer: B
The use of iontophoresis in PD has Level 3 evidence and receives a Grade C recommendation, according to the CUA.

Question 16

What is the consensus of the panel regarding the use of oral agents like potassium para-aminobenzoate (POTABA)?
A. The panel favors it as first-line treatment.
B. There is no consensus among the panel.
C. The panel recommends it with reservations.
D. The panel does not recommend it.

Answer 16

Answer: D
The panel does not recommend the use of potassium para-aminobenzoate (POTABA) as a treatment for PD.

Question 17

What is the age range where congenital penile curvature is typically diagnosed?
A. Adolescence
B. Early childhood
C. Middle age
D. Older age

Answer 17

Answer: A
Congenital penile curvature is typically diagnosed during adolescence.

Question 18

According to the CUA, what is the preferred surgical approach to treat ventral curvature of congenital penile curvature?
A. Plaque excision and grafting
B. Nesbit procedure
C. Dermal graft
D. Plication

Answer 18

Answer: D
For ventral curvature of congenital penile curvature, the CUA recommends the Plication technique as the preferred surgical approach.

Question 19

What is the role of hormonal therapy in congenital penile curvature?
A. Effective and recommended
B. No role or not recommended
C. Under investigation
D. Controversial but still used

Answer 19

Answer: B
Hormonal therapy has no role or is not recommended in the management of congenital penile curvature according to CUA guidelines.

Question 20

What is the recommendation for post-operative erectile function assessment after surgery for congenital penile curvature?
A. Recommended for all patients
B. Not necessary unless there are complications
C. Only if pre-operative evaluation indicated problems
D. Recommended for patients above 40 years only

Answer 20

Answer: A
Post-operative erectile function assessment is recommended for all patients who undergo surgery for congenital penile curvature.

Question 21

What is the primary goal of all Peyronie’s Disease (PD) treatments?

A) Penile elongation
B) Penile girth increase
C) Erection duration improvement
D) Correct penile deformity while preserving penile length and erectile function

Answer 21

D
Explanation: The overarching goal of all PD treatments is to correct penile deformity while preserving penile length and the ability to attain and maintain an erection sufficient for satisfactory sexual intercourse.
Memory tool: Think of “D for Deformity, Duration (length), and Dysfunction (erectile).”

Question 22

Which of the following is NOT considered a surgical procedure for PD?

A) Penile plication
B) Plaque incision/excision with grafting
C) Penile injections
D) Penile prosthesis implantation

Answer 22

C
Explanation: Surgical procedures for PD include penile plication, plaque incision/excision with grafting, and penile prosthesis implantation.
Memory tool: Think of the Three P’s for surgery: Plication, Plaque incision, and Prosthesis.

Question 23

For surgical intervention, PD should be stable for a minimum of how many months after disease onset?

A) 2-4 months
B) 6-12 months
C) 15-18 months
D) 20-24 months

Answer 23

B
Explanation: A general criterion for surgical intervention is a minimum of 6-12 months after disease onset with plaque stability for 3-6 months.
Memory tool: Remember “6-12, 3-6” as a sequence for stability: 6-12 months of disease, 3-6 months of plaque stability.

Question 24

Which of the following is the gold standard for preoperative evaluation in PD?

A) MRI
B) CDU with intracavernosal injection
C) Digital photography
D) X-ray

Answer 24

B
Explanation: Combination of CDU with intracavernosal injection is the gold standard and recommended by the Committee as an integral part of preoperative evaluation.
Memory tool: Think of “Gold CDU” as if it’s a gold album, making it a hit in preoperative evaluations.

Question 25

What should patients be made aware of regarding expectations of surgery?

A) Unrealistic expectations of full recovery
B) Possibility of perfect penile curvature correction
C) Concept of “functionally straight” vs. completely straight
D) None of the above

Answer 25

C
Explanation: Patients should be made aware of the concept of “functionally straight” (penetrative intromission not compromised, residual curvature less than 20º) vs. completely straight.
Memory tool: “F-C, 20 degrees” - Functionally straight to Completely straight with under 20 degrees of curvature

Question 26

What is one primary determinant for dissatisfaction post plication surgery?

A) Excessive straightening
B) Postoperative penile shortening
C) Cost of surgery
D) Duration of the surgery

Answer 26

B
Explanation: Dissatisfaction after plication surgery correlates with postoperative penile shortening.
Memory tool: “B for Beware” of penile shortening after plication surgery.

Question 27

Plication procedures are attractive due to their:

A) High cost
B) High risk of ED
C) High degree of curvature correction
D) Low success rate

Answer 27

C
Explanation: Plication procedures represent the most common type of surgical approach for PD and are attractive due to a high degree of curvature correction.
Memory tool: Plication is for Precision in Curvature correction

Question 28

Which is a complication that may arise from plication surgery?

A) Complete loss of penile sensation
B) Penile hematoma
C) Chronic UTI
D) Severe infection

Answer 28

B
Explanation: Complications may include persistent pain, persistence or recurrence of penile curvature, penile hematoma, and sensation loss.
Memory tool: “PHPS” - Pain, Hematoma, Penile curvature, Sensation loss, are complications you need to consider.

Question 29

What material is most commonly used for grafting in PD?

A) Dermal matrix
B) Small intestinal submucosa
C) Human cadaveric pericardium
D) Synthetic materials

Answer 29

A
Explanation: Autologous dermal matrix grafts are most commonly used in grafting procedures for PD.
Memory tool: “Dermal graft is the A-graft.” As in, the top choice for grafting.

Question 30

What is the major disadvantage of plaque incision and grafting?

A) High cost
B) Shorter procedure time
C) Risk of erectile dysfunction
D) Limited degree of curvature correction

Answer 30

C
Explanation: The primary disadvantage of plaque incision and grafting is the risk of postoperative erectile dysfunction (ED).
Memory tool: “ED after I & G” - Erectile Dysfunction after Incision & Grafting.

Question 31

What is IPP considered the gold standard for?

A) PD without ED
B) PD with refractory ED and severe deformity
C) Mild PD
D) PD in young patients

Answer 31

B
Explanation: IPP remains the gold standard treatment for PD requiring surgery and occurring concurrently with refractory ED, especially when dealing with severe deformity.
Memory Tool: “Golden B’s - Bad ED and Big deformity need IPP.”

Question 32

Which additional procedures may be required alongside IPP placement for a satisfactory surgical outcome?

A) Manual modelling and plication only
B) Manual modelling, plication, and plaque-releasing incisions
C) Manual modelling, plication, plaque-releasing incisions, and grafting
D) None, IPP alone suffices

Answer 32

C
Explanation: The surgeon must be prepared for additional procedures like manual modelling, plication, plaque-releasing incisions, and grafting, especially if the TA defect size confers risk of herniation.
Memory Tool: “C’s the Day” with Complete procedures – Manual modelling, Plication, Plaque-releasing incisions, and Grafting.

Question 33

What’s the commonly used cut-off size for the TA defect that may require additional grafting during IPP?

A) 1 cm
B) 2 cm
C) 3 cm
D) 4 cm

Answer 33

B
Explanation: The commonly used cutoff size for TA defect that requires additional grafting is 2 cm.
Memory Tool: “Two to Do” - 2 cm defect requires you to do grafting.

Question 34

What range of PD deformity correction rates is seen with IPP?

A) 50-75%
B) 60-90%
C) 70-95%
D) 84-100%

Answer 34

D
Explanation: PD deformity correction rates with penile prosthesis implantation range from 84-100%.
Memory Tool: “D for Delightful outcomes” - 84-100% correction rates are possible.

Question 35

What must be discussed during the consent process for PD patients receiving IPP?

A) Risk of prosthesis infection, penile shortening, and mechanical device failure
B) Risk of prosthesis infection, penile shortening, diminished sensitivity, and mechanical device failure
C) Risk of prosthesis infection, penile shortening, diminished sensitivity, mechanical device failure, and persistent curvature
D) All of the above

Answer 35

D
Explanation: During the consent process, patients should be informed of the risks of prosthesis infection, persistent penile shortening or curvature, diminished sensitivity, and mechanical device failure.
Memory Tool: “D for Discuss everything” – Disclose all risks involved.

Question 36

Which of the following best describes the current evidence for Platelet-rich Plasma (PRP) treatment in Peyronie’s Disease (PD)?

Level 1–4, Grade A
Level 1–4, Grade C
No Level 1–4, Grade A–C
Level 2, Grade B

Answer 36

3. No Level 1–4, Grade A–C

Explanation & Memory Aid:
There’s no robust evidence supporting PRP for PD. Think of PRP like a flashy car with no engine; it may look appealing but doesn’t go anywhere in terms of evidence.

Question 37

Your patient asks about stem cell treatment for Peyronie’s disease. What’s your best recommendation?

Encourage enrollment as it’s FDA approved
Mention accruing trials on www.clinicaltrials.gov
Recommend as it has shown Level 1 evidence of efficacy
Suggest they consider it as it has a Grade A recommendation

Answer 37

2. Mention accruing trials on www.clinicaltrials.gov

Explanation & Memory Aid:
Stem cell treatments are in clinical trials and aren’t yet proven for PD. Think of stem cells like a mysterious novel; it’s intriguing, but you don’t yet know the ending (outcome).

Question 38

Question 3:
What kind of evidence exists for penile traction in PD management?

Level 2 evidence, Grade C recommendation
Level 4 evidence, Grade A recommendation
Level 4 evidence, Grade C recommendation
Level 1 evidence, Grade A recommendation

Answer 38

3. Level 4 evidence, Grade C recommendation

Explanation & Memory Aid:
Penile traction has Level 4 evidence and Grade C recommendation. It’s like a low-budget movie that still has a cult following. Some like it; others need more evidence.

Question 39

Which of the following is a benefit of penile traction according to Hellstrom’s group?

Improvement in curvature
Improvement in stretched penile length
Worsening of penile pain
Increased plaque size

Answer 39

2. Improvement in stretched penile length

Explanation & Memory Aid:
According to Hellstrom’s group, routine penile traction may improve stretched penile length. It’s like stretching a rubber band; the longer you stretch, the more you gain, but it won’t bend back to the original shape (won’t affect curvature).

Question 40

What is the Committee’s recommendation for using ESWT for potential penile pain improvement?

Strongly recommend
Recommend with Level 2 evidence, Grade C
Do not recommend
Ambiguous

Answer 40

2. Recommend with Level 2 evidence, Grade C

Explanation & Memory Aid:
ESWT has Level 2 evidence and Grade C recommendation for potential penile pain improvement. Think of ESWT like an over-the-counter painkiller: it may reduce pain, but it’s not a cure-all.

Question 41

Does ESWT have evidence-based support for reducing penile curvature in PD?

Yes
No
Ambiguous
Only from observational studies

Answer 41

2. No

Explanation & Memory Aid:
ESWT does not have evidence-based support for reducing curvature. Imagine ESWT like a rain dance: it might be fascinating, but it doesn’t guarantee rain (curvature reduction).

Question 42

What level of evidence supports the use of radiation therapy (RT) for PD?

Level 1, Grade A
Level 2, Grade C
Level 4, Grade D
None

Answer 42

4. None

Explanation & Memory Aid:
Radiation therapy is not supported for PD. Think of RT like skydiving without a parachute: it’s a risky endeavor with no guaranteed benefit.

Question 43

The alteration of connective tissue by cellular proliferation and expansion of the extracellular matrix in penile traction therapy is mainly due to changes in:

Bone marrow-derived stem cells
Collagen and tissue metalloproteinase expression
Platelet-derived growth factors
Adipose tissue-derived stem cells

Answer 43

2. Collagen and tissue metalloproteinase expression

Explanation & Memory Aid:
Think of collagen and tissue metalloproteinase like the ingredients in a recipe; they’re the key factors that influence the final dish (plaque integrity in PD).

Question 44

When using ESWT for PD, what is the best outcome supported by evidence?

Reduction of plaque size
Resolution or improvement of penile pain
Increase in penile length
Improvement of penile curvature

Answer 44

2. Resolution or improvement of penile pain

Explanation & Memory Aid:
ESWT is like your mom’s home remedy for a cold. It might help you feel better (pain), but it won’t cure you.