What is the treatment for Peyronie's disease?

Treatment of Peyronie's Disease

The treatment of Peyronie's disease should be based on disease phase (active vs. stable), severity of curvature, presence of erectile dysfunction, and impact on sexual function, with intralesional collagenase clostridium histolyticum being the first-line treatment for stable disease with moderate curvature and intact erectile function. 1, 2

Disease Classification and Initial Assessment

Active vs. Stable Disease

• Active disease: Characterized by dynamic symptoms, penile pain, changing deformity, and ongoing inflammation (typically first 3-12 months)
• Stable disease: Symptoms unchanged for at least 3 months, minimal pain, and stable curvature 1

Key Assessment Parameters

• Degree of curvature (measured during erection via intracavernosal injection)
• Presence of palpable plaque
• Erectile function status
• Pain level
• Impact on sexual function and psychological well-being 1

Treatment Algorithm

Active Phase Management

1. Conservative management is recommended during the active phase:

   • NSAIDs for pain management 1, 2
   • Avoid invasive treatments while disease is evolving 1
   • Patient education about disease course 1

2. Not recommended during active phase:

   • Oral therapies including vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or combination of vitamin E with L-carnitine (lack of efficacy) 1, 2
   • Electromotive therapy with verapamil 1
   • Surgical interventions 1, 2

Stable Phase Management

For Patients with Mild-Moderate Curvature (30-90°) and Intact Erectile Function:

1. First-line treatment: Intralesional collagenase clostridium histolyticum (Xiaflex) with modeling

   • Average curvature reduction of 17° (vs. 9.3° with placebo)
   • Minimal risk of penile shortening
   • Potential adverse events: penile ecchymosis (84.2%), swelling, pain, risk of corporal rupture 1, 2

2. Alternative options:

   • Intralesional interferon α-2b (curvature reduction of 13.5° vs. 4.5° with placebo)
   • Intralesional verapamil (conditional recommendation with weak evidence)
   • Penile traction therapy as adjunctive treatment to minimize length loss 2

For Patients with Severe Curvature (>90°) or Hourglass Deformity:

• Surgical intervention with grafting techniques to preserve length 2
  • Plaque incision/excision with grafting for severe deformities 2

For Patients with Concurrent Erectile Dysfunction:

• Penile prosthesis implantation with modeling 1, 2
  • Most effective for addressing both erectile dysfunction and penile deformity
  • May result in some shortening but preserves functional length 2

For Patients with Moderate Curvature but Without Erectile Dysfunction:

• Tunical plication for stable disease with adequate rigidity
  • Results in some penile shortening (1-2 cm on average) 2
  • Simpler procedure with lower risk of postoperative erectile dysfunction compared to grafting 1

Important Considerations and Pitfalls

1. Timing of intervention:

   • Avoid invasive treatments during active phase
   • Wait for disease stabilization (typically 12-18 months after symptom onset with stable curvature for 3-6 months) 2

2. Patient expectations:

   • Complete restoration of pre-disease penile dimensions is often not achievable
   • Address psychological distress related to body image and sexual function 2

3. Surgical complications:

   • Penile shortening with plication procedures
   • Risk of erectile dysfunction with grafting procedures
   • Sensory changes 1, 2

4. Ineffective treatments to avoid:

   • Oral medications like vitamin E, tamoxifen, and omega-3 fatty acids 1, 3
   • Radiation therapy 4, 3
   • Electromotive therapy with verapamil 1

5. Follow-up:

   • Regular assessment of treatment efficacy
   • Monitoring for adverse events, particularly with intralesional treatments
   • Psychological support as needed 1, 5

By following this algorithm and considering the individual patient's disease characteristics, clinicians can provide effective treatment for Peyronie's disease while minimizing complications and optimizing quality of life.