What is the recommended treatment for a 3 cm plaque in Peyronie's disease?

Treatment of 3 cm Plaque in Peyronie's Disease

For a 3 cm plaque in Peyronie's disease, intralesional collagenase clostridium histolyticum (Xiaflex) is the recommended first-line treatment for stable disease with significant curvature, followed by intralesional interferon α-2b as a second-line option. 1

Disease Phase Assessment

Before initiating treatment, it's critical to determine the phase of Peyronie's disease:

• Active phase: Characterized by changing symptoms, pain during erection, and evolving plaque/curvature
• Stable phase: Disease has stabilized (symptoms present for 12-18 months without changes)

Treatment decisions should be made after the disease has stabilized, as most interventional treatments are more effective and appropriate during the stable phase. 1

Treatment Algorithm

First-line treatment (for stable disease with ≥30° curvature):

1. Collagenase clostridium histolyticum (Xiaflex)
   • FDA-approved treatment
   • Average curvature reduction: 17° (vs. 9.3° with placebo)
   • Specifically indicated for palpable plaques with significant curvature
   • Safety considerations: Risk of corporal rupture (0.5%) and severe penile hematoma (3.7%) 1

Second-line treatment:

1. Intralesional interferon α-2b
   • Demonstrated efficacy in stable disease (>12 months duration)
   • Average curvature reduction: 13.5° (vs. 4.5° with placebo)
   • Plaque size reduction: 2.6 cm² (vs. 0.9 cm² with placebo)
   • Dosing: 5 MU every 2 weeks for 12 weeks
   • Side effects: Flu-like symptoms, sinusitis, minor penile swelling (manageable with NSAIDs) 2

Third-line treatment:

1. Intralesional verapamil
   • Weaker evidence for efficacy
   • Side effects: Penile bruising, dizziness, nausea, injection site pain
   • Consider only if other options aren't suitable 2

Non-recommended treatments:

• Extracorporeal shock wave therapy (ESWT)
  • Not recommended for reduction of penile curvature or plaque size
  • Multiple randomized trials showed no significant benefit over placebo 2

Surgical Options (for severe cases or treatment failures):

For patients with severe curvature or when conservative treatments fail:

1. Penile plication - For patients without erectile dysfunction (ED)
2. Plaque incision/excision with grafting - For severe curvature with adequate erectile function
3. Penile prosthesis implantation - For patients with concurrent ED 1

Important Considerations

• Plaque size: A 3 cm plaque is significant and may benefit from intralesional therapy
• Erectile function: Must be assessed as it influences treatment choice
• Pain management: NSAIDs recommended for pain control during treatment 1
• Patient counseling: Set realistic expectations about treatment outcomes
• Monitoring: Regular assessment of treatment efficacy and adverse events is essential

Pitfalls to Avoid

1. Treating during active phase: Most interventional treatments are more effective in stable disease
2. Ignoring erectile function: Concurrent ED requires specific management approaches
3. Unrealistic expectations: Complete resolution of plaque is uncommon
4. Inadequate follow-up: Regular monitoring is needed to assess treatment response and adjust therapy

Remember that Peyronie's disease can cause significant psychological distress, and psychological support may be beneficial alongside physical treatments 1.