In this episode, Dr. Rena Malik, MD, along with guest Dr. Jesse Mills, explores conservative treatment options for Peyronie's ...

can-peyronies-disease-actually-be-treated-without-surgery-ft-dr-jesse-mills

Can Peyronie’s Disease Actually be Treated Without Surgery? Ft. Dr. Jesse Mills

let's talk about conservative options so you know earlier data there was a lot of oral options there was a lot of things that you could try are there oral options now that you recommend yeah the only one would be daily X is uh the uh yeah I mean we've tried things over the years from paba to tamoxifen uh cultra scine pentox ofil is probably the one that had the best data over the years Tom Lou Who Legend up at UC San Francisco did some pretty compelling work with you know observational work with with pentoxy it makes sense it's a it's an inflammatory cyto Kine inhibitor and so if you look at the initial path of physiology we're discussing penis senses it's it's upset it has an injury it starts sending all these cyto kindes down to make a scar what if you could give them something to prevent the body from putting a scar down there and that was that was the rationale for pentox ofyen and it showed maybe 30 40% efficacy in certain men and it had to be in the acute phase which again makes sense CU if it's mature already those cyto kindes are long gone theyve you know they've cleaned up their scaffolding and went on to the next construction site so they're not there anymore but the but the acute phase maybe it work so I'll offer that uh our our guidelines for the American neurologic Association say you know really no oral medication has any degree of evidence that it works but some men want to try something and they don't want to get aggressive with their therapy and so most of those things are harmless and and most men tolerate pentoxil fine so I'll offer it we call it our antii iotic therapy a lot of us will throw in citrine or El citrine which is an amino acid that that is easily converted in the liver to or I'm sorry in the kidney to to uh nitric oxide and so maybe you're increasing the substrate with with citrine and then you're BR blocking the breakdown with tadalfil and then P toxifying actually works on a totally different Cascade so so that works you know some guys do fine with it and we don't know you know about 10% of men will will spontaneously resolve and the acute penal trauma tend to do better I mean there are men that really will break their penis or almost break it not to the point of maybe going to your or my operating room to fix but at least to the point where they know they had a spot they know they had bruising and those can just get better because they have normal wound healing and they just hurt themselves and it got better so maybe you're you're missing or you're you're including some of those men in the pentox ofilion arm that that were going to get better on their own anyway so so I don't really spend a lot of time with conservative therapy uh but I offer it yeah for sure yeah and what so when someone comes in in the act in the early phases what do you tell them what's their chance of getting worse I mean there's no great studies to show this there's some of the earlier studies from the 1970s that said it was a third a third and a third right so a third get better third stays the same a third gets worse we know that's not true at all and so nowhere near a third get better uh and most of the time in the the the acute phase they will notice a pretty dramatic change I mean could wake up the next morning and have a 45 degree angulation and those men they tend to stay in that in that realm so they what they do what they get acutely is what there what there is and so I don't typically quote them numbers because again I'm really against just saying just go home and don't do anything about it I mean almost everybody I at least offer some kind of oral therapy and I don't do any of the transdermal therapies that are out there that people are selling for stupid amounts of money for topical Vera aill and there's a really great really elegant again quote John uh mohal on this study where where he put top rapil on men took them to the O for their plaque excision and graft and then you know sent the gra the plaque and there's zero rill ever gets anywhere near the plaque right so uh so the transdermals just there's just no real good evidence that they work at this point very expensive um but you know they're looking at new emoon and looking at new ways to do it there's some interesting subcutaneous thoughts that if you could get under the the dermis and some of these long in subcutaneous reservoirs that's kind of cool I'm kind of interested in that uh but uh but nothing really even in a in a phase one study yet but uh but those are things that my mind thinks about is if you could get something under the skin that just sits there in a reservoir then then and then slowly eludes maybe there's something to that yeah yeah that is interesting what about uh Shockwave therapy yeah so I I think the data on Shockwave are compelling now for ere dysfunction for upregulation of of smooth muscle and and so I think that's probably going to be very close to being more widely accepted in the scientific Community has been offered as you know for 20 years or so in the ponies I just never I never understood the mechanism right if you don't understand the mechanism then it's it's hard to to promote something the one thing I would have a shock wave that I'd be very interested in is in and again this would all be experimental but if you combine shock wave with something that actually effects change in the plaque mhm yeah because the shock wave would be like the daily talil maybe yeah same sort of exactly and and shock wave does have you there pretty interesting daa in the orthopedic literature about it promotes wound healing promotes upregulation of um tissue healing right so so great but I don't know that we can go in and shock a mature plaque and make it go away so you need something to make the plaque go away and then potentially shock it and that that's interesting and that's something that uh that I really want to look at more I mean I know anecdotally there are men that that are doing interlesional therapy and and shock wave and I think if we can get a nice trial together for that I'd be super excited to see that because I I think right now the world of Shockwave is is there's a lot of fascinating research being done a lot of it in Europe that that I'm I'm very excited to see where it goes not not just in in a rectile dysfunction but other other Urologic issues and chronic pelvic pain for example which you know a lot more than I about but but I'm super excited in the microbiome changes so so yeah no I I'm definitely interested very interested but but I can't quote you a paper yet are there other things like transdermal whatever Verapamil or other things that are being marketed to patients that are not necessarily effective there there's uh you know there's another newer uh molecule that that's out there that that uh has a better it's basically just neopine so it's just wraid with a different emolient and it uh you know the idea is that maybe it gets into the skin more but again never done study you know we need to see will that emoon allow this this molecule to get further in and it's still a calcium channel blocker so it's still you know just a just a generic different form of Verapamil yeah I mean the transdermal penetration and then through a plaque that's hard that's really difficult it's hard you got to get through the neurovascular bundle I mean there's a lot of real estate between the the skin and the and the plaque yeah and then as we were saying you know plaques are heterogeneous they're not all just chunks of collagen there's calcium deposition in it there's a lot of other it's a very very wild west of of uh inflammatory proteins in there as Dr Ellis waru studying so yeah so I I I think it's it's just a you know a Sav it it could be purely the fact that when you're putting in anything topically you're rubbing it in you maybe doing a little modeling you know and that modeling of breaking up the protein because we know that if just even that mechanical changes in traction from both the impress study as well as as penile traction devices it may seem to do something so maybe if you're really vigorously uh massaging a topical in there you can be you know putting anything on it but it's the mechanical the mechanics that's doing the heavy lifting so let's talk about modeling and traction devices what is modeling and how can patients do it safely modeling is is purely just stretching the penis mostly in the flaccid State and the way I describe men to do it is to just grab the head of their penis and pull until it hurts at the base of their penis we our penis is held to our pubis by suspensory ligaments so you can't just keep pulling it and so pull it until you feel those ligaments engage and hold it there for about 30 seconds and relax and do it again at least three times a day and all you're doing is you're trying to longitudinal eyesee those those plaque proteins that are abnormal and maybe training it to to go in the direction you want to go the second part of modeling is to just Flex the penis in opposite the direction that it's bent so if you curve up you put your penis on the bottom side of your penis and pull down right as the where right wherever your curvature is great so that would be your fulcrum and you again as part of an interlesional therapy modeling Works modeling independently has pretty good data traction is kind of passive modeling where you you know you said it and forget it and that is multiple different traction devices on the market from 30 bucks to 600 bucks and essentially all you're doing is you're wearing braces for your penis so the idea of of traction is that that that constant strain on those proteins is actually modeling the or changing the the uh the fiber blast infrastructure which is what sets down the new healthy collagen into a more linear pattern so you're not getting that scrambled egg plaque of of what a collagen protein plaque looks like and just kind of you know elongating it and getting it back also and for those people that are interested in it which I know is a small subset of your population it can improve penile length too so there is something there is something to that and the question is how compliant de have be how long you know is it like anything else that's Physical Therapy you get maybe 2 cm of your of your lost penile length back but are you doing this every day for the rest of your life or can you do it for three months and it stays and really really don't have amazing you know annual data on this yeah yeah I I agree I think that traction is great it's safe it's pretty easy to do but it does require sort of a commitment and maybe a long-term commitment we don't know right yeah and I think the only thing I I do have a little I I have some concern around traction and and and combining it with interlesional therapy just because of the bruising swelling that can happen I definitely have had men that have felt a lot more discomfort with traction even had some skin breakdown so you have to be really careful uh with that situation is and and guys you know some people overdo it right and if you say do it for a half hour a day they'll do it for seven hours a day and then you can get some some nerve stretch a little bit of neuropraxia where you get a little numb penis so so right very safe if if uh used as directed exactly used as directed yeah when you have a rectile dysfunction and paronis you know we we counsel patients sometimes you can do something like intracavernosal injections of medication so can that um cause another plaque right if someone is already at risk for getting these plaques can that cause another plaque and if you don't have any plaques and you're just a regular guy like are you because you're potentially injecting usually around the same place every time are you at risk as well I love this question because I don't understand it the when you look at all of the risk factors for for ponis comes up over and over again in uh intracavernosal injections so you're you're sticking a vasoactive agent into the into the corporate cavernosa not into the Tunica and this is sort of a pet suspicion of mine is that when men and and again this is sort of in the older days a lot of those literature comes from before even you know the pd5 inhibitor days so here's a here's a therapy brand new in 1981 882 883 where men that had not had an erection for decades could go to their doctor's office go to the corner store essentially and some of these pop-up shops and get an injection and then all of a sudden they say whoa my penis is curved well maybe it got ponis 10 years ago and now this is the first Direction you've seen to know that you actually have a plaque so I don't I don't know I mean I I definitely see a lot more Corporal fibrosis with intracavernosal therapy where the actual penile tissue the rectile tissue with repeated injections in certain men will develop thickening so I I don't know truly how much of a risk factor it is for developing ponis as it is just for the fact that you've had a phow penis for a long period of time and the first time you got an erection whoa here it is having said that the I still think that intracavernosal therapy is amazing and and I have men that have been on it for decades and and I love doing penile implant surgery I do a lot of them and I think it's an amazing operation but I never sell a guy on a penile implant before I say hey look here's a if you're cool with this have I got a medication for you it's like two bucks a shot really safe if we get the dosering right I'm going to teach you how to do it and you're going to be Off to the Races then you do that what's the worst can happen doc well you could develop scar tissue and you're going to need a penile implant but right now the pills aren't working what are our options you're going to need a penile implant right so that's sort I look at in cavanos therapy if they develop a mild curvature as a result of just age and genetics and all the other things we discussed you we'll deal with that later but uh but yeah I like I like ICI is is a great therapy for the right person yeah I agree and the needles are really small so it's the the trauma to to the tuna is like nothing right right right um so they're really small needles yes

Dr.

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