Collagenase Injections for Pain Associated with Penile Curvature in Peyronie's Disease
Intralesional collagenase clostridium histolyticum (CCH) is not indicated for pain management in Peyronie's disease and should not be offered specifically for pain relief. 1
Understanding Collagenase Treatment in Peyronie's Disease
Indications for Collagenase
- CCH (Xiaflex) is FDA-approved specifically for the reduction of penile curvature in patients with stable Peyronie's disease with curvature between 30° and 90° who maintain intact erectile function 1, 2
- The American Urological Association (AUA) guidelines clearly state that "intralesional collagenase is a therapy for curvature; it does not treat pain or erectile dysfunction" 1
- CCH treatment requires a palpable plaque confirmed on physical examination and stable disease without active progression 2, 3
Pain Management in Peyronie's Disease
- For patients experiencing pain in the active phase of Peyronie's disease, oral non-steroidal anti-inflammatory medications are the recommended treatment option 1, 3
- Pain should be assessed using a visual analog scale and periodically reassessed to measure treatment efficacy 1
Evidence on Collagenase and Pain
Clinical Trials and Pain Outcomes
- The IMPRESS I and II trials, which established the FDA-approved protocol for CCH, focused on curvature reduction rather than pain relief 1
- These definitive trials included patients with average PD symptom durations of 46.8-57.6 months, indicating stable rather than acute disease 1
- While some recent research has explored CCH use in the acute phase with reported improvements in pain scores 4, 5, these studies are limited and not reflected in current guidelines
Treatment Protocol and Considerations
- The approved protocol involves up to eight injections of 10,000 U over 24 weeks, combined with clinician and patient modeling 1, 2
- Patients should be counseled about potential adverse events, including penile ecchymosis, swelling, pain, and rare but serious complications like corporal rupture 1, 6
- In the IMPRESS trials, 84.2% of patients in the collagenase groups experienced at least one adverse event, with most being mild or moderate 1
Alternative Approaches for Pain Management
Recommended Pain Management Options
- For patients with active disease and pain, the AUA guidelines specifically recommend oral NSAIDs as the appropriate treatment 1, 3
- Pain management should be periodically reassessed to measure treatment efficacy 1
Treatment Algorithm
- For active disease with pain: Use oral NSAIDs for pain management 1
- For stable disease with curvature 30°-90° and intact erectile function: Consider CCH for curvature reduction, not pain relief 1, 2
- If pain persists despite NSAID treatment: Reassess disease phase and consider other treatment options 1
Important Considerations and Pitfalls
- CCH treatment should only be administered by clinicians experienced in urological disease treatment 2
- The average improvement in curvature with CCH is modest (approximately 17° versus 9.3° with placebo), and patients should have realistic expectations 1, 2
- Using CCH specifically for pain relief represents off-label use not supported by major guidelines and could delay appropriate pain management 1
- Patients should be informed that while curvature may improve with CCH, this is not a treatment specifically targeting pain relief 1, 2