What is the recommended dose of intraleional verapamil (injection of verapamil into the lesion) for Peyronie's disease?

Intralesional Verapamil Dosing for Peyronie's Disease

The recommended dose of intralesional verapamil for Peyronie's disease is 10-15 mg diluted in 6-10 mL of solution, administered every 2-3 weeks for a minimum of 6 injections, with optimal results often requiring approximately 12 injections. 1, 2, 3

Treatment Protocol Details

Dosing:

• Standard dose: 10-15 mg verapamil per injection
• Dilution: 6-10 mL of solution
• Frequency: Every 2-3 weeks
• Duration: Minimum of 6 injections, with optimal results often requiring around 12 injections
• Administration technique: Single-puncture or multiple-puncture approach directly into the plaque

Patient Selection:

Intralesional verapamil is most appropriate for:

• Patients with localized, palpable plaques
• Those with mild to moderate curvature
• Patients in either active or stable phase of disease

Efficacy and Expectations

Intralesional verapamil has shown variable effectiveness:

• Plaque softening: Reported in nearly all patients (100%) 4
• Curvature improvement: 42-76% of patients report subjective improvement 4, 3
• Objective curvature reduction: Documented in 54% of patients 3
• Pain resolution: 97% of patients with pain experience relief, typically after 2-3 injections 3
• Sexual function improvement: 72-83% of patients report improvement 4, 3

However, the AUA guidelines note that evidence for intralesional verapamil is weak (Grade C evidence strength), and clinicians should carefully consider whether this treatment is appropriate given uncertainty about its efficacy and the availability of other more effective treatments 1.

Mechanism of Action

Verapamil, a calcium channel blocker, works by:

• Inhibiting synthesis and secretion of extracellular matrix molecules
• Increasing collagenase activity
• Reducing collagen production by fibroblasts
• Decreasing plaque volume and softening fibrotic tissue 5, 6

Adverse Events

Patients should be counseled about potential adverse events:

• Penile bruising and ecchymosis
• Pain at the injection site
• Dizziness
• Nausea 1

These side effects are generally mild and transient.

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis of Peyronie's disease
   • Determine disease phase (active vs. stable)
   • Assess curvature severity, plaque characteristics, and pain

2. Treatment Decision:

   • For patients with localized plaques and mild-moderate curvature: Consider intralesional verapamil
   • For patients with severe curvature (>30°) and stable disease: Consider collagenase clostridium histolyticum (first-line) or interferon α-2b (second-line) instead 1, 7

3. Verapamil Protocol:

   • Start with 10-15 mg verapamil diluted in 6-10 mL
   • Inject directly into plaque every 2-3 weeks
   • Continue for minimum 6 injections
   • Assess response after 6 injections
   • If responding but not optimal, continue up to 12 injections 2
   • Discontinue if no response after 3 months

4. Follow-up:

   • Assess pain, curvature, and sexual function at each visit
   • Document objective measurements of curvature
   • Consider alternative treatments if inadequate response after 3 months

Important Considerations

• Younger patients may respond better to intralesional verapamil therapy 2
• Beneficial effects typically appear within the first three months of treatment 5
• Patients with curvature >30° at presentation may be better candidates for surgery or other treatments 5
• The AUA guidelines suggest that intralesional collagenase clostridium histolyticum and intralesional interferon α-2b may be more effective options for patients with stable disease 1, 7