What are the treatment options for Peyronie's disease?

Treatment Options for Peyronie's Disease

Intralesional collagenase Clostridium histolyticum (CCH) is the most strongly recommended treatment for Peyronie's disease with curvature between 30° and 90° in patients with intact erectile function. 1, 2

Disease Assessment and Classification

• Peyronie's disease has two distinct phases that require different management approaches:

  • Active phase: characterized by pain, progressive deformity, and worsening curvature 1, 3
  • Stable phase: characterized by stable curvature without pain or progressive deformity 1, 3

• Initial evaluation should include:

  • Documentation of penile curvature, deformities, presence and degree of plaque 1
  • Assessment of erectile function with or without pharmacotherapy 1
  • Office intracavernosal injection test with or without ultrasound to accurately measure deformity 1

Treatment Options by Disease Phase

Active Phase Treatment

• NSAIDs may be offered for pain management 1, 3
• Daily tadalafil 5 mg has shown evidence of reducing curvature progression and improving symptoms 1, 3
• Avoid unproven oral therapies as they may delay more effective interventions 1, 3

Stable Phase Treatment

Non-surgical Options (First-line)

• Intralesional collagenase Clostridium histolyticum (CCH) with modeling:

  • Moderate recommendation (Evidence Strength Grade B) 1
  • Appropriate for patients with curvature between 30° and 90° 1, 2
  • Requires intact erectile function 1, 2
  • Average improvement of approximately 17° reduction in curvature 2
  • Should be administered by experienced urologists 2

• Low-intensity extracorporeal shock wave therapy (LI-ESWT):

  • May be offered for penile pain relief 1
  • Not effective for curvature reduction or plaque size reduction 1

• Penile traction therapy (PTT):

  • Works through collagen remodeling 3
  • Requires extended daily use (2-8 hours) 3

Surgical Options (When Non-surgical Approaches Fail)

• Only consider after disease has been stable for 3-6 months 1, 4
• For patients with intact erectile function:
  • Tunical shortening procedures for curvatures <60° 4
  • Tunical lengthening with grafting for curvatures >60° or complex deformities 4
• For patients with erectile dysfunction:
  • Penile prosthesis implantation 4

Ineffective Treatments to Avoid

• Oral treatments lack proven efficacy and are not recommended, including: 1, 3
  • Pentoxifylline
  • Vitamin E
  • Tamoxifen
  • Potassium para-aminobenzoate (potaba)
  • Colchicine
  • Omega-3 fatty acids

Important Considerations and Potential Complications

• Patients should be counseled that Peyronie's disease does not lead to malignancy 3
• CCH treatment may cause adverse events including penile ecchymosis, swelling, pain, and rare but serious complications like corporal rupture 2
• Tunical lengthening procedures carry significant risk of postoperative erectile dysfunction (up to 50%) 4
• While non-surgical treatments can improve curvature, the average improvement is modest and some patients may still have residual curvature requiring additional interventions 2, 5
• If erectile dysfunction is present alongside Peyronie's disease, it should be treated first or concomitantly 3

Treatment Algorithm

1. Determine disease phase (active vs. stable)
2. For active phase: Pain management with NSAIDs and daily tadalafil 5mg
3. For stable phase with curvature 30°-90° and intact erectile function: Intralesional CCH
4. For stable phase with other presentations: Consider PTT, LI-ESWT, or surgical options based on erectile function status and curvature severity
5. For patients with erectile dysfunction: Address ED first or simultaneously with Peyronie's treatment 3, 5