Can collagen injections be used to treat penile fracture, injury, and curvature 12 months post-injury?

Collagen Injections for Post-Penile Fracture Curvature

Collagenase of Clostridium histolyticum (CCH) injections may be considered for penile curvature resulting from a penile fracture that occurred 12 months ago, but only if the curvature is between 30° and 90° with a palpable plaque and the patient maintains intact erectile function. 1

Assessment of Candidacy for Collagen Injections

• Penile fracture typically results from direct trauma to the erect penis, usually during sexual intercourse, and requires immediate surgical intervention to prevent long-term complications including curvature 2, 3
• For patients with residual curvature after penile fracture repair, treatment options depend on:
  • Degree of curvature (CCH is FDA-approved for curvatures between 30° and 90°) 1
  • Presence of a palpable plaque (required for CCH treatment) 1
  • Erectile function status (must be intact for CCH to be considered) 1
  • Stability of the curvature (treatment is indicated for stable disease without active pain or progressive deformity) 4

Treatment Algorithm for Post-Fracture Penile Curvature

• For active disease (pain, progressive curvature, deteriorating deformity):

  • NSAIDs for pain management 4
  • Daily tadalafil 5 mg may help reduce curvature progression and improve symptoms 4
  • Avoid invasive treatments until disease stabilizes 4

• For stable disease (no pain, stable curvature for at least 3-6 months):

  • For curvature between 30°-90° with intact erectile function:

    • Collagenase Clostridium histolyticum (CCH) injections are a first-line option 1
    • Treatment follows FDA-approved protocol: 0.58 mg per injection into the plaque, with proper spacing between treatment cycles (6 weeks) 1
    • Patient should be counseled that average improvement is modest (approximately 17° reduction in curvature) 1

  • For severe curvature (>60°) or if CCH fails:

    • Surgical options include tunical shortening, tunical lengthening with grafting, or penile prosthesis implantation if erectile dysfunction is present 4

Important Considerations and Limitations

• CCH treatment should be administered by a urologist experienced in urological disease treatment 1
• Patients should be counseled about potential adverse events including penile ecchymosis, swelling, pain, and rare but serious complications like corporal rupture 1
• If curvature decreases to less than 15° after treatment cycles, subsequent cycles should not be administered 1
• The safety of more than one treatment course has not been established 1
• Alternative non-surgical options with limited evidence include:
  • Penile traction therapy (PTT) which works through collagen remodeling 4
  • Extracorporeal shockwave therapy (ESWT) which may help with pain but has no proven effect on curvature 4
  • Vacuum erection devices (VEDs) which have limited evidence as monotherapy 4

Surgical Options if Non-Surgical Approaches Fail

• Surgery should only be considered after disease has been stable for 3-6 months 4
• For patients with erectile dysfunction, penile prosthesis implantation is indicated 4
• For patients with preserved erectile function:
  • Tunical shortening procedures for curvatures <60° 4
  • Tunical lengthening with grafting for curvatures >60° or complex deformities 4
• Novel approaches like the PICS technique (using collagen fleece) may be considered for severe curvature correction during penile prosthesis implantation 5

Pitfalls to Avoid

• Delaying treatment of the initial penile fracture can lead to higher rates of complications including persistent curvature 2, 6
• Oral treatments (vitamin E, tamoxifen, pentoxifylline) lack proven efficacy and may delay more effective interventions 4
• Calcium channel antagonists (verapamil, nicardipine) show no meaningful improvement versus placebo 4
• Patients should be informed that while CCH can improve curvature, some may still have residual curvature requiring additional interventions 1
• Tunical lengthening procedures carry a significant risk of postoperative erectile dysfunction (up to 50%) 4