Complications and other concerns with intralesional injection therapy with collagenase clostridium histolyticum for Peyronie’s disease

tau.amegroups.com © Translational Andrology and Urology. All rights reserved. The article by Yafi et al. reports on a well-designed survey of Sexual Medicine Society of North America members regarding complications following intralesional injection with collagenase clostridium histolyticum (CCH) for Peyronie’s disease (PD) (1). Only 100 of the 693 (14%) members responded to the report, which may be an indication of the limited adoption and/or experience with this drug as of the time of this survey. The side-effects reported are not surprising and correspond to the published reports from the CCH pivotal trials including that hematoma and ecchymosis are the most frequently observed adverse events following treatment with this drug (2,3). The extent and severity of these local side-effects are interesting given the small amount of fluid injected (0.25 cc) and the small needle used (27 gauge), as compared to intralesional verapamil or interferon where up to 10 cc’s of fluid is injected using a 25-gauge needle (4,5). Ecchymosis is not an uncommon finding after injection with these drugs, but it is rare to have significant hematomas or blood blisters. Therefore, is there something peculiar to CCH that causes the more extensive ecchymosis and hematomas? It has been speculated that this occurs as a result of a local histamine response to the fragments of collagen released following injection of CCH. Since these complications are common following CCH injection, it would seem that the physician would be welladvised to inform the patient up-front that this is a likely side-effect of the drug and not necessarily one that should cause distress. The patient should know that the hematomas and ecchymosis typically resolve without sequelae within 2 weeks after injection (2,3). Many physicians have suggested applying a post-injection compression dressing which is left on for 2–24 hours. As not all patients experience this problem, our approach has been that following initial injection, the patient is advised to manually compress the injection area for approximately 10 minutes, but if they do develop a significant ecchymosis, then on subsequent visits a gentle compression dressing with Coban should be applied overnight. What was more significant in this survey was the relatively frequent incidence of corporal rupture reported by 34% of physicians at a median of 5 days from the last CCH injection. The most commonly reported cause of rupture was during vigorous intercourse in 38% but up to 31% had this occur during a spontaneous nocturnal/morning erection. As expected, these ruptures occurred in the area of the treated plaque and 67% of the responding physicians did explore the patient and repair the rupture. The patient information pamphlet does recommend “waiting 2 weeks after the second injection before resuming sexual activity (6).” But 44% of the noted corporal ruptures were found to occur beyond the 2-week window and no fractures occurred beyond the 30-day mark. The authors therefore suggest that patients should be counseled to “exert caution and refrain from vigorous intercourse within the first 30 days after the second injection of the treatment cycle.” This seems to be reasonable, albeit difficult to enforce advice. Interestingly, Editorial