What are the treatment options for Peyronie's disease?

Treatment Options for Peyronie's Disease

The treatment of Peyronie's disease should follow a structured approach based on disease phase (active vs. stable), with intralesional collagenase injections being the only FDA-approved non-surgical therapy for stable disease with curvature between 30° and 90°. 1

Disease Classification

• Active Disease: Characterized by dynamic symptoms, penile pain, developing plaque, and progressive deformity, typically lasting 3-12 months 1
• Stable Disease: Symptoms unchanged for at least three months, minimal or no pain, established plaque, and stable curvature 1

Treatment Options by Disease Phase

Active Phase Treatment

1. Pain Management

   • NSAIDs are recommended as first-line therapy for penile pain during the active phase 1
   • Pain should be assessed using a visual analog scale and periodically reassessed 1

2. Oral Medications

   • NOT RECOMMENDED: Vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, pentoxifylline, or combination therapies have no proven efficacy 1, 2
   • These ineffective treatments may delay more effective interventions 2
   • PDE5 inhibitors (particularly tadalafil 5mg daily) may reduce collagen deposition and show lower curvature progression rates 1

3. Intralesional Therapies

   • Generally reserved for stable disease 3
   • Collagenase Clostridium histolyticum (CCH) is not indicated for pain management in active disease 3

Stable Phase Treatment

1. Non-surgical Options

   • Intralesional Collagenase (CCH/Xiaflex): The only FDA-approved non-surgical therapy for stable disease with curvature between 30° and 90° with intact erectile function 1, 3

     • Protocol: Up to eight injections of 10,000 U over 24 weeks with modeling 3
     • Average improvement: 17° versus 9.3° with placebo 3

   • Penile Traction Therapy (PTT): Works through collagen remodeling but requires extended daily use (2-8 hours) 1, 4

   • Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT): May help with pain relief but not recommended for curvature reduction 1

2. Surgical Options (for stable disease only, typically after 12-18 months of symptoms)

   • Tunical Plication: Recommended for patients with adequate rigidity for coitus, with curvature improvement rates >90% 1

     • Best for patients with intact erectile function or ED responsive to medications 1

   • Plaque Incision/Excision with Grafting: Option for patients with adequate rigidity, with curvature improvement rates generally >80% 1

     • Most appropriate for patients with intact erectile function or ED responsive to oral medications 1

   • Penile Prosthesis Surgery: Recommended for patients with both ED and penile deformity preventing intercourse despite other therapies 1

     • May require adjunctive procedures like modeling, plication, or incision/grafting for optimal results 1

Treatment Algorithm

1. Initial Assessment:

   • Determine disease phase (active vs. stable) 1
   • Assess for erectile dysfunction 1
   • Document penile curvature and plaque characteristics 1

2. For Active Disease:

   • NSAIDs for pain management 1
   • Consider PDE5 inhibitors (tadalafil 5mg daily) 1
   • Avoid ineffective oral therapies 1, 2

3. For Stable Disease:

   • Without ED:

     • Mild curvature (<30°): Consider observation if not interfering with intercourse 1
     • Moderate curvature (30-90°): Consider intralesional collagenase injections 1, 3
     • Severe curvature (>90°) or failed conservative therapy: Consider surgical options 1

   • With ED:

     • ED responsive to medication: Consider plication or plaque incision/grafting 1
     • ED not responsive to medication: Consider penile prosthesis 1

Common Pitfalls to Avoid

• Pursuing unproven oral therapies that delay effective treatment 1, 2
• Failing to distinguish between active and stable disease phases 1
• Using collagenase specifically for pain relief, which is not its indicated use 3
• Not considering the impact on erectile function when selecting treatments 1
• Expecting complete resolution of penile curvature with non-surgical treatments 3, 5