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 Following Penile Fracture

For a 43-year-old man with a history of penile fracture 12 months ago presenting with penile curvature, pain during intercourse, palpable plaque, and 70-degree dorsal curvature, intralesional collagenase clostridium histolyticum (CCH) injections are the recommended next step in management.

Rationale for Collagenase Injections

According to the American Urological Association (AUA) guidelines, this patient meets the criteria for definitive treatment of Peyronie's disease because:

1. His symptoms have been present for 12 months, indicating stable disease (stable phase is defined as symptoms unchanged for at least 3 months) 1
2. He has significant curvature (70 degrees, well above the 30-degree threshold)
3. He has a palpable plaque
4. He experiences pain during intercourse

CCH (Xiaflex) is FDA-approved as first-line treatment for stable Peyronie's disease with these exact characteristics, with an average curvature reduction of 17° compared to 9.3° with placebo 1.

Treatment Protocol

The FDA-approved protocol for CCH treatment includes:

• 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
• Up to 4 treatment cycles administered at approximately 6-week intervals 1

Safety Considerations

Important safety considerations for CCH treatment include:

• Risk of corporal rupture (penile fracture) in 0.5% of patients
• Severe penile hematoma in 3.7% of patients
• Common adverse events include penile ecchymosis, swelling, and pain 1

Alternative Treatment Options

While other options exist, they are less appropriate for this patient:

1. Observation (Option A): Not appropriate as the patient has stable disease with significant curvature (70 degrees) and pain during intercourse, which warrants active treatment 1.

2. Extracorporeal shock wave therapy (ESWT) (Option B): Not recommended by AUA guidelines for reduction of penile curvature or plaque size. It may only be considered for pain management, but this patient's primary issues are curvature and pain during intercourse 1.

3. Intralesional verapamil injections (Option C): Has only a conditional recommendation with weak evidence according to AUA guidelines. Less effective than CCH 1.

4. Stem cell therapy (Option E): Not mentioned in current guidelines as a standard treatment option for Peyronie's disease 1.

Treatment Efficacy

Research has shown that CCH is effective for patients with significant curvature:

• Studies demonstrate meaningful improvement in penile curvature after CCH treatment 2
• For patients who don't achieve sufficient improvement after one round of treatment (8 injections), additional rounds may provide further benefit 3

Surgical Options

Surgical intervention should be considered only if CCH treatment fails:

• Penile plication for patients without erectile dysfunction
• Plaque incision/excision with grafting for patients with adequate erectile function and severe curvature
• Penile prosthesis implantation for addressing both erectile dysfunction and penile deformity 1, 4

Key Pitfalls to Avoid

1. Treating too early: Ensure disease is stable (symptoms present for at least 12 months) before initiating definitive treatment 1
2. Unrealistic expectations: Counsel patient that complete restoration of pre-disease penile dimensions is often not achievable 1
3. Inadequate follow-up: Regular assessment of treatment efficacy and monitoring for adverse events is essential 1
4. Ignoring psychological impact: Provide psychological support as this condition can cause significant distress 1

In conclusion, based on the patient's presentation with stable Peyronie's disease, significant curvature, palpable plaque, and pain during intercourse, intralesional collagenase clostridium histolyticum (CCH) injections represent the most appropriate next step in management.