Dr. Ludlow, please tell us a little bit about your background and your experience of treating patients with Peyronie's disease

I am a board certified urologist and have been in practice since 1996. I trained under John Mulcahy at Indiana University which provided a comprehensive training experience treating patients with Peyronie's disease. I have continued to actively treat patients with Peyronies's disease and have developed an extensive experience with this patient population.

Presently, I am able to offer both surgical and non-surgical options to all patients with Peyronie's disease regardless of severity or prior treatments. This includes medical options, injectible options and all forms of surgical options including plication procedures, plaque incision/excision with grafting and placement of an internal penile pump with a variety of modeling techniques.

Roughly, how many Peyronie's patients do you treat each year?

75-100.

What is the average age of your Peyronie's patients?

45.

How many of your patients fall approximately into each of the following groups: mild, moderate, and severe Peyronie's symptoms?

20% mild, 60% moderate, 20% severe.

How common do you think Peyronie's is? Do you think it is on the rise, e.g. due to lifestyle changes or environmental issues, or are men becoming more open about seeking assistance?

It is my opinion that men are seeking appropriate medical advice much more promptly than in the past and I am seeing more patients with this disease.

The real issue is that very few urologists have appropriate training and, therefore, patients need to be better informed regarding who can provide appropriate options in the evaluation and treatment of this disease.

How important is early diagnosis in your opinion? Can men expect better results the sooner they start treatment and why?

I do think that earlier evaluation and treatment can, in most cases, lead to better outcomes. This disease is multifactorial in its etiology and that can certainly have a direct impact on outcomes. What we should be doing is being more proactive about our data and data analytics.

Physicians have been accustomed to working in silos. We need to get out of those silos and collaborate. We need to combine our data, figure out what works and what doesn't and, in the end, our patients will be the winners. This shouldn't be difficult in the era of advanced information technology. We need someone to take the lead.

Can you describe the non-surgical treatments you recommend to your patients? What influences which treatments you recommend?

Presently I most often recommend a course on non-surgical treatment(s) to patients in whom I think have an evolving plaque. I am very up front with them regarding the lack of data confirming efficacy of these non-surgical opotions but I do recommend this as standard first line therapy in this particular group of patients. This is combined with careful follow up examinations and sometimes doppler ultrasonography. The vast majority of patients have a stable plaque as very few patients seek medical advice early on or they are not referred early on.

My standard non-surgical recommendations include Vitamin E, colchicine and pentoxifylline. These are prescribed individually, sequentially or in combination depending on the patient's particular situation. I will also use interferon, verapamil or collagenase injections depending on the particular patient's situation which includes insurance considerations.

What do you consider satisfying result from non-surgical Peyronie's treatment?

Stability of the plaque, resolution of pain and the ability to have satisfying intercourse for both partners. The patient's perception needs to be considered as well.

Some patients with 30 degrees of dorsal curvature and slight hourglassing at the locus of the plaque are completely comfortable with their situation while some patients with 15 degrees of dorsal curvature, no hourglassing have ongoing issues and further treatment after careful informed consent makes sense.

What is your view on using supplements as part of Peyronie's treatment plan?

I usually tell patients that supplements are fine but that we really don't have adequate studies that allow concrete recommendations.

Have you recommended using traction device or penis pump to treat penis curvature? If so, what is your experience of them? When do you recommend using each device?

I have recommended the use of a traction device, less so, the use of an external pump in the treatment of Peyronie's disease. I tell patients that the outcomes are variable but that we do know the better success is seen in those patients who are able to use the device for an extended period of time. This option is always included in my discussion on the various treatment options that are available

What do you recommend for men that also suffer from low erection quality / erectile dysfunction?

That all depends on the patients specific evaluation of their erectile function. We frequently perform doppler ultrasonography all patients fill out a SHIM/IIEF. Plicating an appropriate patient who responds to PDE5 inhibitors or penile injection therapy is a reasonable option. In the setting of more severe Peyronie's disease I frequently recommend the placement of an internal penile pump with standard intra-operative modeling techniques.

Approximately how many (%) of your patients do not respond to non-surgical treatment and therefore require penis surgery? Have you been able to identify any common characteristics among those patients?

75% of the respond 'poorly' to non-surgical options but not all of these patients ultimately choose surgery.

Two factors that predict failure of non-surgical options are calcification of the plaque (seen with Doppler ultrasonography) and the length of time since the onset of the curvature-the longer they've had the disease the less likely they are to responding to non-surgical options.

There is some risk involved with any surgery. In your experience, how common are serious side effects after penis surgery (e.g. erectile dysfunction, penile shortening, reduced penile sensation, loss of elasticity)?

Penile shortening occurs in virtually anyone who undergoes surgery for Peyronie's disease be it plication, incision/excision with grafting or placement of an internal penile pump with modeling. I am very explicit about this issue.

Because of our inability to accurately objectively assess erectile function I always counsel prospective patients about this risk especially with plaque excision and grafting. Nerve related issues (numbness and/or pain) in dorsal plaque excision and grafting is common in the short term but resolves in most patients. We are very up front and comprehensive when it comes to our informed consents.

For patients that have undergone surgery to treat their Peyronie's disease, do you recommend some post operation treatment for them? If yes, what do you recommend?

I am a firm believer in the use of erectile restoration techniques (external pumps, PDE5 inhibitors, penile injection therapy) after surgical correction of Peyronie's disease especially with plaque incision/excision and grafting

What do you recommend that men with Peyronie's disease should do (or not do) to prevent the disease from getting worse?

I encourage patients to have regular erections. Daily manual stimulation (not necessarily to the point of climax) is encouraged. It is also my sense that avoiding the partner dominant position during intercourse is important and I review this issue with them as well

How do you address the emotional side of Peyronie's? What can men do to deal with the distress caused by the disease?

I am very up front regarding the emotional aspects of Peyronie's disease and we do offer referral to a therapist whose trained in this issue. He is very good and most patients find this to be very helpful.

In your opinion, how can partner or friend best support man with Peyronie's disease?

I always tell patients, from the beginning, that Peyronie's disease is a couples disease - it's not just a male issue and we encourage partners to attend all appointments.

What can be done to raise the awareness of Peyronie's, both among the public and health professionals?

I would start with a strong social media campaign.

What does the future hold for Peyronie's patients? Are there any interesting new treatments on the horizon (short term and long term)? Do you think Peyronie's will ever become curable?

The answer here lies in our ability to combine our patient data. I don't know how many urologists in the UIS have an active practice in treating Peyronie's patients but I want to know what others are doing and what they find helpful. We need to collaborate.

Anything you would like to add?

I can only hope that we continue to train urologists to be able to identify this disease and offer appropriate treatment options or referrals. We need to talk about this potentially debilitating disease and bring this out of the closet.

Dr. John Ludlow, thank you very much for taking the time to do this interview with My Peyronie's. For more information about Dr. Ludlow, visit Western Michigan Urological Associates .