What is the initial management for a patient with Peyronie's disease presenting with hard fibrous tissue at the base of the penis?

Initial Management of Peyronie's Disease with Hard Fibrous Tissue at Base of Penis

For patients with Peyronie's disease presenting with hard fibrous tissue at the base of the penis, the initial management should include NSAIDs for pain control and daily tadalafil 5mg to reduce curvature progression. 1, 2

Disease Phase Assessment

First, determine which phase of Peyronie's disease the patient is experiencing:

• Active/Acute Phase:

  • Characterized by pain during erection
  • Progressive penile deformity/curvature
  • Ongoing inflammation
  • Typically lasts 6-18 months

• Stable/Chronic Phase:

  • No pain during erection
  • Stable penile curvature (unchanged for at least 3 months)
  • Disease present for at least 12-18 months

First-Line Management for Active Phase

1. Pain Management:

   • NSAIDs are recommended for pain control 1, 2
   • Pain should be assessed using a visual analog scale and periodically reassessed 2

2. Prevention of Disease Progression:

   • Daily tadalafil 5mg has demonstrated lower curvature progression rates and improved symptoms versus controls 1
   • PDE5 inhibitors may reduce collagen deposition and increase apoptosis in Peyronie's disease 1

3. Patient Education and Counseling:

   • Discuss natural history of the disease
   • Reassure patient that Peyronie's doesn't lead to malignancy
   • Set realistic expectations about treatment outcomes
   • Psychological support may be beneficial 2

Additional Conservative Treatment Options

• Low-intensity extracorporeal shockwave therapy (LI-ESWT):

  • Effective for pain relief but no significant effect on curvature or plaque size 1

• Penile Traction Therapy (PTT):

  • Works through collagen remodeling
  • Can increase penile length (average 1cm) when used as adjunct therapy
  • Requires extended daily use (2-8 hours)
  • Limited evidence but appears safe 1, 2

Important Considerations

• Avoid ineffective oral treatments: Pentoxifylline, vitamin E, tamoxifen, procarbazine, potassium para-aminobenzoate (potaba), and omega-3 fatty acids lack proven efficacy and may delay more effective interventions 1

• Calcium channel antagonists: Verapamil and nicardipine lack strong evidence for clinical use, showing no meaningful improvement versus placebo 1, 2

• Concurrent erectile dysfunction: If present, PDE5 inhibitors should be considered as first-line treatment with a starting dose of 50mg sildenafil taken approximately 1 hour before sexual activity 2

• Monitoring: Patients should be monitored for disease progression and reassessed after at least 3 months of stability before considering more definitive treatments 2

When to Consider Advanced Therapies

If conservative management fails after the disease has stabilized (typically 12-18 months):

• Intralesional injections: Collagenase Clostridium histolyticum (Xiaflex) is recommended for stable disease with significant curvature (at least 30 degrees) 2

• Surgical options: Consider when disease is stable for at least 3 months with curvature that impedes sexual intercourse 2

  • Penile plication for patients without erectile dysfunction
  • Plaque incision/excision with grafting for severe curvature
  • Penile prosthesis implantation for patients with concurrent erectile dysfunction

Caution

• Avoid delaying effective interventions with unproven therapies
• Be aware that surgical options carry risks including penile shortening and erectile dysfunction
• Set realistic expectations about treatment outcomes to minimize psychological distress