What is the next step in managing a 43-year-old man with a history of penile fracture, presenting with penile curvature and pain during intercourse, and a palpable plaque with 70 degree dorsal penile curvature?

Management of Peyronie's Disease in a Patient with Penile Fracture History

The next step in managing this patient with stable Peyronie's disease and significant penile curvature should be intralesional collagenase clostridium histolyticum (CCH) injections.

Patient Assessment and Disease Characterization

This 43-year-old man presents with:

• History of penile fracture 12 months ago
• Current symptoms: penile curvature and pain during intercourse
• Physical findings: palpable, soft plaque
• 70-degree dorsal penile curvature on intracavernosal injection
• Disease appears to be in stable phase (symptoms present 12 months after initial injury)

Rationale for CCH Treatment

The American Urological Association (AUA) guidelines indicate that:

1. The patient's disease is in the stable phase, as:

   • Symptoms have been present for 12 months
   • Typically, Peyronie's lesions become stable at 12-18 months 1
   • Stable disease is a prerequisite for definitive treatment 2

2. CCH (Xiaflex) is the FDA-approved first-line treatment for stable Peyronie's disease with:

   • Palpable plaque
   • Significant curvature (patient has 70° curvature, well above the 30° threshold) 2, 3

3. Clinical efficacy of CCH has been demonstrated with:

   • Average curvature reduction of 17° (vs. 9.3° with placebo) 2
   • Studies showing improvement in 94.8% of patients with mean reduction of 19.1° or 42.9% from baseline 4

Why Other Options Are Not Appropriate

1. Observation (Option A): Not appropriate because:

   • Patient has significant curvature (70°) causing pain during intercourse
   • Disease is already stable (12 months post-injury)
   • Active intervention is indicated for symptomatic stable disease 2

2. Extracorporeal shock wave therapy (ESWT) (Option B): Not recommended because:

   • AUA guidelines explicitly state: "Clinicians should not use ESWT for the reduction of penile curvature or plaque size" 1
   • While ESWT may improve pain, it has not shown efficacy for curvature reduction 1, 2

3. Intralesional verapamil injections (Option C): Less appropriate because:

   • AUA guidelines note "evidence for the use of intralesional verapamil is weak" 1
   • Guidelines recommend "carefully considering whether use of this treatment is appropriate given substantial uncertainty regarding its efficacy" 1
   • Better alternatives (CCH) with stronger evidence are available

4. Stem cell therapy (Option E): Not mentioned in guidelines as an established treatment option for Peyronie's disease

Treatment Protocol for CCH

If implementing CCH treatment, the FDA-approved protocol includes:

1. A treatment cycle consisting of:

   • Two CCH injection procedures (0.58 mg) 1-3 days apart
   • Followed by penile modeling procedure 1-3 days after the second injection 3

2. Up to 4 treatment cycles may be administered at approximately 6-week intervals 3

3. Important safety considerations:

   • Risk of corporal rupture (penile fracture) in 0.5% of patients
   • Severe penile hematoma in 3.7% of patients
   • Available only through a restricted program (XIAFLEX REMS Program) 3

Conclusion

Based on the patient's presentation with stable disease, significant curvature, and pain during intercourse, intralesional collagenase clostridium histolyticum (CCH) injections represent the most appropriate next step in management, as supported by current guidelines and FDA approval.