What are the treatment options for Peyronie’s disease?

Treatment Options for Peyronie's Disease

Intralesional collagenase clostridium histolyticum with modeling by clinician and patient is the most effective treatment for stable Peyronie's disease with penile curvature between 30-90 degrees in patients with intact erectile function. 1

Disease Overview and Diagnosis

Peyronie's disease (PD) is an acquired penile abnormality characterized by fibrosis of the tunica albuginea, which may be accompanied by:

• Penile curvature/deformity
• Pain with or without erection
• Erectile dysfunction
• Psychological distress

Before initiating treatment, proper diagnosis is essential:

• Document penile deformity, pain, and impact on intercourse
• Perform physical examination to assess palpable penile abnormalities
• Conduct in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound to evaluate:
  • Degree of curvature
  • Plaque characteristics
  • Vascular integrity of the penis 1

Treatment Algorithm Based on Disease Phase

1. Active Phase (Dynamic symptoms)

Active disease is characterized by changing symptoms, typically within the first 12-18 months:

• For pain management:

  • Oral non-steroidal anti-inflammatory medications 1
  • Pain should be assessed using visual analog scale and periodically reassessed

• Treatments to AVOID during active phase:

  • Vitamin E
  • Tamoxifen
  • Procarbazine
  • Omega-3 fatty acids
  • Combination of vitamin E with L-carnitine
  • Electromotive therapy with verapamil
  • Radiotherapy 1

2. Stable Phase (Symptoms unchanged for ≥3 months)

A. For patients with intact erectile function:

1. First-line therapy:

   • Intralesional collagenase clostridium histolyticum with modeling
     • Most appropriate for patients with curvature 30-90 degrees
     • Patient must have intact erectile function 1

2. Alternative options:

   • Intralesional verapamil

     • Less effective than collagenase but may be considered
     • Potential side effects: penile bruising, dizziness, nausea, injection site pain 1

   • Intralesional interferon α-2b

     • May reduce curvature and plaque size
     • Side effects include flu-like symptoms, sinusitis, and minor penile swelling 1

   • Extracorporeal shock wave therapy (ESWT)

     • May improve penile pain but NOT recommended for curvature or plaque size reduction
     • Note: Pain commonly resolves over time without intervention 1

B. For patients with erectile dysfunction and/or severe deformity:

1. Surgical options:

   • Tunical plication

     • For patients with adequate rigidity (with or without pharmacotherapy)
     • High success rates (>90%) for curvature improvement 1

   • Plaque incision/excision with grafting

     • For patients with adequate rigidity but more severe deformity
     • Curvature improvement rates generally >80% 1

   • Penile prosthesis implantation

     • For patients with erectile dysfunction and penile deformity
     • May require additional procedures (modeling, plication, incision/grafting) during surgery
     • Inflatable penile prosthesis is preferred over semi-rigid devices 1

Important Considerations and Pitfalls

1. Timing of intervention:

   • Surgical reconstruction should only be considered after disease stabilization (typically 12-18 months after symptom onset) 1
   • Premature intervention may lead to suboptimal outcomes as the disease is still evolving

2. Ineffective treatments to avoid:

   • Oral therapies (vitamin E, tamoxifen, procarbazine, omega-3 fatty acids)
   • Electromotive therapy with verapamil
   • Radiotherapy 1

3. Patient counseling:

   • Discuss realistic expectations regarding treatment effects and potential adverse events
   • Some patients may choose not to pursue treatment after understanding the natural disease course
   • Pain often resolves spontaneously over time
   • Curvature and deformity are less likely to resolve without intervention 1, 2

4. Psychological impact:

   • Many men experience emotional distress, depressive symptoms, and relationship difficulties
   • These psychological effects often persist, suggesting PD has lasting impact 1

5. Treatment selection pitfalls:

   • Treating during active phase with invasive procedures
   • Using unproven therapies that delay effective treatment
   • Failing to assess erectile function before selecting treatment approach
   • Not considering patient's goals and expectations 1, 2

By following this evidence-based approach and selecting the appropriate treatment based on disease phase, erectile function status, and severity of deformity, patients with Peyronie's disease can achieve significant improvement in both physical symptoms and quality of life.