What is the appropriate workup and treatment for a 60-year-old man with suspected Peyronie's disease?

Workup and Treatment for 60-Year-Old Male with Suspected Peyronie's Disease

For a 60-year-old man with suspected Peyronie's disease, obtain a detailed history focusing on penile curvature onset, pain, erectile function, and sexual impact, perform a genital examination with penile palpation for plaques, and determine if the disease is active (changing symptoms, pain) or stable (unchanged ≥3 months) to guide treatment selection.

Diagnostic Workup

Essential History Elements 1

• Onset and duration of penile curvature and deformity
• Presence and severity of penile pain (with or without erection)
• Precipitating trauma during intercourse (though many patients won't recall a specific event)
• Progression of symptoms over time
• Impact on sexual function: ability to achieve penetration, partner satisfaction, psychological distress
• Erectile function status with or without medications
• Prior treatments attempted

Physical Examination 1

• Genital examination with stretching and palpation of the flaccid penis
• Document palpable plaques (though often not palpable in flaccid state)
• Assess for penile shortening or other deformities
• Note circumcision status and any anatomical anomalies

Critical Distinction: Active vs. Stable Disease 1, 2

Active Disease (acute phase):

• Defining feature: Penile pain with or without erection
• Progressive curvature or deformity deterioration
• Symptoms changing dynamically
• Plaques may not be fully developed
• Erectile function may be intact or compromised

Stable Disease (chronic phase):

• Defining feature: Symptoms unchanged for ≥3 months
• Pain typically absent or minimal
• Stable penile curvature (uniplanar or biplanar)
• Palpable plaques often present
• Most common presentation: dorsal, dorso-lateral, or ventral deformity

Advanced Assessment 1

Perform intracavernosal injection (ICI) test with or without duplex Doppler ultrasound prior to any invasive intervention to:

• Objectively assess penile curvature degree in erect state
• Evaluate plaque size, location, and calcification
• Document erectile function and vascular integrity
• Measure actual deformity (patient perception often differs from objective measurement)

Treatment Algorithm

Patient Counseling (All Patients) 2, 1

• Reassure: Peyronie's disease does not lead to malignancy
• Natural history: Pain typically resolves spontaneously in most patients; curvature less likely to improve without treatment
• Realistic expectations: Treatment effects are often modest
• Psychosocial impact: Address anxiety, depression, relationship difficulties (affects 54% of patients)

Active Disease Treatment 2

Pain Management:

• NSAIDs for penile pain 2
• Daily tadalafil 5 mg demonstrated lower curvature progression rates and improved symptoms versus controls 2
• Low-intensity extracorporeal shockwave therapy (LI-ESWT) for pain relief (no effect on curvature) 2

What NOT to Use: Avoid oral therapies including pentoxifylline, vitamin E, tamoxifen, procarbazine, potassium para-aminobenzoate (potaba), and omega-3 fatty acids—these lack proven efficacy and may delay effective interventions 2

Emerging Options:

• Penile traction therapy (PTT): Requires 2-8 hours daily use; safe with no serious adverse effects; works through collagen remodeling 2
• PDE5 inhibitors (tadalafil/sildenafil) may reduce collagen deposition and improve pain/erectile function 2

Stable Disease Treatment 2, 1

Non-Surgical Options:

1. Intralesional collagenase clostridium histolyticum (CCH) - though withdrawn from European market 2:

   • Most evidence-based intralesional therapy
   • Appropriate for curvature 30-90° with intact erectile function
   • Mean curvature reduction: 17° vs 9.3° placebo (modest 7.7° difference) 1
   • Requires clinician modeling after each cycle + patient home modeling 3x/day
   • Common adverse events: penile ecchymosis (84.2%), swelling, pain; rare corporal rupture 1

2. Intralesional interferon α-2b 1:

   • 5 MU every 2 weeks for 12 weeks
   • Curvature reduction: 13.5° vs 4.5° placebo
   • Pain resolution: 67.7% vs 28.1% placebo
   • Adverse effects: sinusitis, flu-like symptoms, minor swelling (treat with NSAIDs, hydration)
   • Most appropriate for stable disease (>12 months duration)

3. Intralesional verapamil 1:

   • Weak evidence; conditional recommendation
   • Calcium channel antagonists lack strong evidence versus placebo 2

4. Penile traction therapy 2:

   • Can be used as monotherapy or multimodal approach
   • Average length increase: 1 cm when used as adjunct
   • Requires extended daily use but appears safe

5. Multimodal approaches 2:

   • PDE5 inhibitor + CCH superior to CCH alone for curvature and erectile function
   • Injectable verapamil + antioxidants + diclofenac better pain reduction than verapamil alone

Do NOT use:

• Electromotive therapy with verapamil: No meaningful improvement versus placebo 1
• Oral therapies: Same as active phase—not recommended 2

Surgical Treatment 2

Indications:

• Conservative treatments failed
• Stable disease (≥3 months unchanged)
• Significant functional impairment or distress

Surgical Options (based on erectile function and deformity):

• Tunical plication: First-line for preserved erectile function, less severe curvature
• Plaque incision/excision with grafting: More severe curvatures or complex deformities
• Penile prosthesis implantation: Erectile dysfunction not responding to pharmacotherapy, with or without adjunctive procedures for persistent curvature

Common Pitfalls

1. Prescribing ineffective oral therapies (vitamin E, tamoxifen, etc.) delays effective treatment and wastes patient time/money 2
2. Not distinguishing active from stable disease leads to inappropriate treatment selection 1
3. Failing to perform ICI test before invasive intervention results in inadequate assessment of true deformity 1
4. Underestimating psychosocial impact: 54% report relationship difficulties; address mental health proactively 1
5. Setting unrealistic expectations: Even best treatments show modest improvements (e.g., CCH: 7.7° difference from placebo) 1

Practical Approach for This 60-Year-Old Patient

1. Determine disease phase through history (pain presence, symptom progression)
2. If active: Consider daily tadalafil 5 mg + NSAIDs for pain; avoid ineffective oral therapies
3. If stable: Perform ICI test to document curvature; discuss intralesional options (if available) or penile traction therapy
4. If erectile dysfunction present: Address ED first or concomitantly
5. If conservative treatment fails and significant functional impairment: Refer for surgical evaluation

The 2025 EAU guidelines 2 represent the most current evidence and should guide management, with the understanding that non-surgical treatments have limited efficacy and surgery remains the definitive option for severe, stable disease with functional impairment.