What is the approach to evaluate, manage, and assess response in Peyronie’s disease?

Evaluation, Management, and Response Assessment in Peyronie's Disease

Intralesional collagenase clostridium histolyticum (Xiaflex) is the first-line treatment for stable Peyronie's disease with curvature of at least 30 degrees, with surgical options reserved for those with severe curvature or concurrent erectile dysfunction. 1

Initial Evaluation

Clinical Assessment

• Detailed genital examination to identify:
  • Penile shaft fibrosis/plaques
  • Testicular size abnormalities
  • Foreskin retractability issues 1
• Pain assessment using visual analog scale 1
• Documentation of:
  • Degree of curvature
  • Plaque size and location
  • Presence of erectile dysfunction

Curvature Measurement

• Intracavernosal injection (ICI) is the gold standard for accurate curvature measurement
• At-home photography and vacuum erection device methods tend to underestimate curvature by approximately 8-9 degrees compared to ICI 2
• Curvature measurement is critical as treatment eligibility often requires ≥30 degrees of curvature 1

Disease Classification and Management Algorithm

Active Phase (0-12 months)

1. Pain Management:

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

2. Conservative Measures:

   • Penile traction therapy to preserve/increase penile length (average gain 1cm) 1
   • Vacuum erection devices to prevent length loss 1

Stable Phase (after 12-18 months of symptoms)

1. First-Line Medical Treatment (for curvature ≥30°):

   • Intralesional collagenase clostridium histolyticum (Xiaflex)
     • Average curvature reduction: 13.5° (vs 4.5° with placebo)
     • Average plaque size reduction: 2.6 cm² (vs 0.9 cm² with placebo) 1
     • Safety concerns: risk of corporal rupture (0.5%), severe penile hematoma (3.7%) 1

2. Second-Line Medical Treatment:

   • Intralesional interferon α-2b 1
   • Intralesional verapamil (conditional recommendation with weak evidence) 1
     • Side effects: penile bruising, dizziness, nausea, injection site pain 1

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

   • For patients with good erectile function:

     • Penile plication for less severe curvature (preserves erectile function but results in some shortening) 1
     • Plaque incision/excision with grafting for severe curvature (higher risk of postoperative ED) 1

   • For patients with concurrent erectile dysfunction:

     • Penile prosthesis implantation with modeling (addresses both ED and deformity) 1, 3

Management of Concurrent Erectile Dysfunction

• PDE5 inhibitors as first-line treatment
  • Sildenafil starting at 50mg, 1 hour before sexual activity
  • Dose range: 25-100mg based on response and tolerability 1
• Consider combination of CCH with PDE5 inhibitors for improved outcomes 1

Response Evaluation

• Reassess curvature using consistent measurement method (preferably ICI) 2
• Monitor for:
  • Pain resolution (expected in majority of patients even without treatment) 3
  • Changes in plaque size
  • Improvement in erectile function
  • Psychological impact
• Treatment success criteria:
  • Reduction in curvature (goal: <30° or improvement allowing satisfactory intercourse)
  • Pain resolution
  • Improved sexual function
  • Patient satisfaction

Special Considerations

• Most patients without treatment will experience stable or worsening symptoms; spontaneous resolution is rare 3
• Psychological support is beneficial as the condition causes significant emotional distress 1
• Setting realistic expectations about treatment outcomes is crucial 1
• Potential complications to monitor: recurrent retraction, erectile dysfunction, penile shortening, infection, and preputial edema 1