How to manage Peyronie's disease?

Management of Peyronie's Disease

Intralesional collagenase clostridium histolyticum (Xiaflex) is the recommended first-line treatment for stable Peyronie's disease with curvature of at least 30 degrees, showing average curvature reduction of 13.5° compared to 4.5° with placebo. 1

Disease Assessment and Stabilization

• Peyronie's disease requires careful evaluation of:

  • Penile curvature/deformity
  • Pain (using visual analog scale)
  • Disease stability (symptoms present for 12-18 months)
  • Erectile function

• Treatment should only be initiated after the disease has stabilized (12-18 months from onset) 1

• NSAIDs are recommended for pain control during the active phase 1

Treatment Algorithm

Active Phase (Symptoms Changing)

1. Conservative management:
   • NSAIDs for pain management
   • Daily tadalafil 5mg to reduce curvature progression
   • Low-intensity extracorporeal shockwave therapy (LI-ESWT) for pain relief 1

Stable Phase (Symptoms Stabilized for 3+ Months)

1. First-line treatment for curvature ≥30°:

   • Intralesional collagenase clostridium histolyticum (Xiaflex) 1
   • Important safety considerations: risk of corporal rupture (0.5%), severe penile hematoma (3.7%) 1

2. Second-line options:

   • Intralesional interferon α-2b 1
   • Penile traction therapy as adjunct (can increase penile length by average 1cm) 1
   • Vacuum erection devices to prevent penile length loss 1

3. Surgical options (for stable disease with severe curvature):

   • For patients with normal erectile function:

     • Penile plication (preserves erectile function but may cause some shortening) 1
     • Plaque incision/excision with grafting (for severe curvature, higher risk of post-op ED) 1

   • For patients with erectile dysfunction:

     • Penile prosthesis implantation with modeling 1

Management of Concurrent Erectile Dysfunction

• PDE5 inhibitors are appropriate first-line treatments
• Starting dose of sildenafil: 50mg taken ~1 hour before sexual activity
• Dose range: 25-100mg based on response and tolerability
• Maximum frequency: once daily 1
• Consider combination therapy of collagenase with PDE5 inhibitors for improved outcomes 1

Psychological Support

• Psychological counseling is beneficial as Peyronie's disease can cause significant emotional distress 1
• Setting realistic expectations about treatment outcomes is crucial 1

Common Pitfalls to Avoid

1. Treating before disease stabilization:

   • Definitive treatment should only be initiated after at least 3 months of disease stability 1

2. Overreliance on unproven therapies:

   • Calcium channel antagonists like verapamil lack strong evidence and show no meaningful improvement versus placebo 1
   • While vitamin E is commonly prescribed, evidence from the American Urological Association guidelines does not strongly support its use as monotherapy 1

3. Neglecting psychological impact:

   • The condition causes significant psychological distress that requires addressing 1

4. Failure to monitor for complications:

   • Patients should be monitored for recurrent retraction, erectile dysfunction, penile shortening, infection, and preputial edema 1

By following this structured approach based on disease phase and patient characteristics, Peyronie's disease can be effectively managed to improve quality of life and sexual function.