Survey reveals gaps in basic knowledge of Peyronie's disease

Orlando, FL-Results of a survey of Peyronie's disease (PD) knowledge and practice patterns among urologists in the United States show that while a large portion of the respondents consider themselves experts in sexual medicine, many show gaps in basic knowledge and most see very few patients per month.

When it comes to management, most are opting for a very conservative approach initially, but the vast majority perform surgery for PD, reported first author John P. Mulhall, MD, who was associate professor of urology at Weill Medical College of Cornell University, New York, at the time of the study. The presentation was made at the 2008 AUA annual meeting.

"The findings on PD knowledge, and especially those that show many urologists are operating on patients despite seeing very few patients, are somewhat concerning. PD patients are very litigious, and this is not the kind of surgery urologists should be performing on an occasional basis," said Dr. Mulhall, currently director of the sexual medical program at Memorial Sloan-Kettering Cancer Center, New York.

"Although there is a paucity of evidence-based medicine in this area, I think there is an onus on the AUA and the Sexual Medicine Society of North America to begin this project to help practicing urologists conduct rational management of PD that will provide patients with realistic expectations about their condition and have an impact on the course of their disease," Dr. Mulhall said.

The absence of practice guidelines, combined with his experience in seeing patients in daily practice, provided the motivation for conducting the survey, Dr. Mulhall told Urology Times.

"My practice is largely focused on sexual health, and I see up to 20 PD patients per week. As many of these men are seeking a second or third opinion, I have realized that there is a tremendous variability in what patients are being told about PD by their community urologists," he explained.

For the survey, Dr. Mulhall collaborated with Laurence A. Levine, MD, of the University of Illinois, Chicago, to create a 46-item questionnaire. It was e-mailed to AUA members with the help of the AUA Office of Education. The survey had an 8% response rate, which is average for surveys of this type, and represented a reasonable sample size of 639 urologists.

Two-thirds of the respondents were in private practice, 40% said they were specialists in sexual medicine, and 16% were fellowship trained in sexual medicine. About three-fourths indicated that they were trained in PD management, and a similar proportion said they were trained in PD surgery in their residency.

"It was interesting to me that these urologists seemed to have a greater focus on sexual medicine than the typical general urologist. However, I was surprised that about two-thirds of the respondents actually saw fewer than five PD patients per month and by the number claiming they had surgical training, because there are few centers in the U.S. where it is taught in a structured fashion," noted Dr. Mulhall.

Treatment practices

Responses to questions about PD prevalence and natural history highlighted gaps in knowledge. Most respondents significantly underestimated the prevalence and spontaneous resolution rates estimated in the literature, while about 20% overestimated the spontaneous resolution rate.

Just over half of the urologists believed that early PD was best managed by observation, 59% started medical treatment initially, and only 3% referred patients to a subspecialist in PD. When asked what they considered first-line medical therapy, oral therapy was selected by 72%, transdermal by 5%, and 8% said they used intralesional injections. Forty-five percent of the respondents were performing intralesional therapy, which reaffirms the idea that the group in general had a greater interest in PD than the average community urologist, Dr. Mulhall said.

Also surprisingly, vitamin E was the most commonly used oral agent, and 27% of respondents were using transdermal verapamil.

"True experts in PD would also probably consider oral therapy as first line, but the popularity of vitamin E is surprising since there is no robust trial showing it has any benefit for preventing PD progression or inducing resolution of curvature," Dr. Mulhall noted.

"Similarly, I am not aware of any robust data showing efficacy of transdermal verapamil other than the Fitch trial, which was fatally flawed. Furthermore, I am not aware of data demonstrating that transdermal verapamil actually ever penetrates the plaque. I think this is something urologists often prescribe to make the patients feel better without having any significant positive impact on their disease."

The most common type of surgery performed was penile plication, followed by penile implant surgery. Few surgeons were doing plaque incision and grafting.

"This is concerning because urologists offering surgical intervention for PD should be capable of performing all three types of PD surgery to optimize the care of any individual patient," Dr. Mulhall said. "Every patient cannot be treated appropriately by a urologist who is only able to perform one or two of the surgical procedures."