What are the common pitfalls in managing Peyronie's disease?

Common Pitfalls in Management of Peyronie's Disease

The most significant pitfalls in managing Peyronie's disease include inadequate disease phase assessment, inappropriate treatment timing, unrealistic patient expectations, and failure to address concurrent erectile dysfunction.

Disease Phase Assessment and Treatment Timing

• Failure to distinguish between active and stable disease phases: Treatment should only be initiated after disease stability (12-18 months of unchanged symptoms) for definitive interventions 1
• Premature surgical intervention: Surgery should only be considered after 3-6 months of disease stability 2
• Inadequate pain assessment: Pain should be evaluated using a visual analog scale and regularly reassessed 1

Treatment Selection Errors

• Inappropriate first-line therapy selection:

  • Intralesional collagenase clostridium histolyticum (Xiaflex) is recommended as first-line for stable disease with significant curvature (≥30°) 1
  • NSAIDs should be used for pain management in the active phase 1
  • Daily tadalafil 5mg may reduce curvature progression 1

• Overreliance on oral therapies: Most oral therapies lack strong evidence as monotherapy 1, 3

• Underutilization of multimodal approaches:

  • Combination of collagenase with PDE5 inhibitors may be superior to collagenase alone 2, 1
  • Penile traction therapy as adjunct treatment can increase penile length (average 1cm) 2, 1

Surgical Approach Errors

• Inappropriate surgical technique selection:

  • Tunical lengthening procedures are recommended for severe shortening, curvature >60°, or complex deformities without ED 2
  • Penile plication is suitable for patients without ED but results in some shortening 1
  • Penile prosthesis implantation should be reserved for patients with concurrent ED unresponsive to medical therapy 2

• Inadequate postoperative care:

  • Failure to implement penile rehabilitation using vacuum erection devices (VEDs) and penile traction therapy to prevent length loss 2
  • Not prescribing daily PDE5Is to enhance nocturnal erections and graft perfusion 2

Management of Concurrent Conditions

• Overlooking erectile dysfunction:
  • Patients with compromised erectile function should be prioritized for maintaining erectile function 1
  • PDE5 inhibitors should be considered as first-line for concurrent ED 1
  • Penile prosthesis implantation should be considered for patients with both PD and ED unresponsive to medical therapy 2, 1

Patient Counseling and Expectation Management

• Inadequate patient counseling:

  • Patients may be hesitant to discuss symptoms unless directly asked 4
  • Many patients are unaware that treatments exist 4
  • Incidental diagnosis rates are as high as 16% 4

• Unrealistic expectations:

  • Failure to inform patients about potential ED risk (up to 50%) after lengthening procedures 2
  • Not discussing potential penile shortening with certain surgical approaches 1
  • Neglecting psychological impact of the condition 1

Safety Considerations

• Overlooking treatment complications:
  • Risk of corporal rupture (0.5%) and severe penile hematoma (3.7%) with collagenase treatment 1
  • Adverse events including penile ecchymosis, swelling, and pain with Xiaflex 1
  • Flu-like symptoms with interferon α-2b 1

Follow-up and Monitoring

• Inadequate follow-up: Patients should be monitored for disease progression and reassessed after at least 3 months of stability before considering definitive treatments 1

• Failure to monitor for complications: Potential complications include recurrent curvature, erectile dysfunction, penile shortening, infection, and preputial edema 1

By avoiding these pitfalls and following evidence-based guidelines, clinicians can optimize outcomes for patients with Peyronie's disease, improving both physical function and quality of life.