What is the recommended injection for treating Peyronie's disease?

Recommended Injection Treatment for Peyronie's Disease

Intralesional collagenase Clostridium histolyticum (CCH, Xiaflex) is the recommended first-line injection treatment for Peyronie's disease with palpable plaque and curvature ≥30°, based on its FDA approval and demonstrated efficacy in reducing penile curvature. 1

Treatment Algorithm Based on Disease Phase

Active Phase (Pain, Progressive Deformity)

• First-line options:

  • NSAIDs for pain management 2
  • Daily tadalafil 5mg (shown to reduce curvature progression) 2
  • Low-intensity extracorporeal shockwave therapy (LI-ESWT) for pain relief 2

• Emerging option:

  • CCH injections may be considered in active phase (showing 27.4-37.4% curvature reduction in early studies) 3

Stable Phase (No Pain, Stable Curvature for 3-6 months)

• First-line injection: Collagenase Clostridium histolyticum (CCH)

  • Average curvature reduction: 17° (vs 9.3° with placebo) 1
  • Treatment protocol: Two injections 24-72 hours apart per cycle, up to 4 cycles at 6-week intervals 4
  • Requires penile modeling 24-72 hours after second injection 5

• Second-line injection: Interferon α-2b

  • Average curvature reduction: 13.5° (vs 4.5° with placebo) 1
  • Adverse events: flu-like symptoms, sinusitis, minor penile swelling

• Third-line injection: Verapamil (conditional recommendation, weak evidence)

  • Adverse events: penile bruising, dizziness, nausea, injection site pain 1

Efficacy of CCH Treatment

• CCH works by breaking down collagen in the penile plaque 6
• Phase III IMPRESS studies demonstrated significant improvement in:
  • Penile curvature deformity (34.4% reduction from baseline) 4
  • Patient-reported bother scores (3.3 point improvement on 0-16 scale) 4
• Modeling after injection significantly improves outcomes (32.4% curvature improvement with modeling vs minimal improvement without) 5

Safety Considerations

• Most adverse events with CCH are mild to moderate and localized to the penis 6
• Serious complications include:
  • Penile hematoma (3.7% of patients)
  • Corporal rupture/penile fracture (0.5% of patients) 1
• Treatment should be administered by urologists trained in the proper injection technique

Important Caveats

• Patients must have a curvature of at least 30° to be considered for CCH treatment 1
• Disease should be stable for 3-6 months before definitive treatment with CCH 1
• Oral treatments (pentoxifylline, vitamin E, tamoxifen, potaba) are not recommended due to lack of proven efficacy 2
• For patients with concurrent erectile dysfunction, consider PDE5 inhibitors or surgical options including penile prosthesis implantation 2, 1
• Calcium channel antagonists like verapamil lack strong evidence for clinical use, showing no meaningful improvement versus placebo 2

Multimodal Approaches

• CCH combined with PDE5 inhibitors may be superior to CCH alone for improving curvature and erectile function 2
• Penile traction therapy as adjunct treatment can increase penile length (average 1cm) 2
• Combination therapy may provide additional benefits, though further research is needed 7