What is a typical treatment approach for an adult with Peyronie's disease?

Treatment Prescription for Peyronie's Disease in a 45-Year-Old Adult

Initial Assessment and Disease Phase Determination

First, determine whether the patient has active or stable disease, as this fundamentally dictates treatment approach. Active disease is characterized by dynamic symptoms, penile pain, developing plaque, and progressive deformity, typically lasting 3-12 months, while stable disease shows symptoms unchanged for at least three months with minimal pain and stable curvature 1.

For Active Phase Disease (Pain, Progressive Symptoms <12 Months)

Prescription:

• Ibuprofen 400-600 mg orally every 6-8 hours as needed for pain 2, 1
• Tadalafil 5 mg orally once daily 1

Patient Instructions:

• Take ibuprofen with food to minimize gastrointestinal upset 2
• Tadalafil should be taken at approximately the same time each day, with or without food 1
• Maintain adequate oral hydration 2
• Pain should improve within 3-12 months as disease stabilizes 1
• Avoid aggressive sexual activity that may worsen penile trauma 3

Counseling Points:

• NSAIDs are the recommended first-line treatment for penile pain during the active phase 2, 1
• Tadalafil may help reduce collagen deposition and lower curvature progression rates 1
• Approximately 20% of patients experience spontaneous improvement during the active phase 4
• Most patients will transition to stable disease within 3-12 months 1

For Stable Phase Disease (Symptoms Stable >3 Months, Curvature 30-90°, Intact Erectile Function)

Prescription:

• Xiaflex (collagenase clostridium histolyticum) 0.58 mg intralesional injection into the penile plaque 5
• Treatment protocol: Two injections per cycle (administered 1-3 days apart), with cycles repeated every 6 weeks for up to 4 cycles (maximum 8 injections over 24 weeks) 5, 1

Patient Instructions:

• Penile modeling exercises must be performed by the patient starting 1-3 days after the second injection of each cycle, performed daily for 6 weeks 5
• Avoid sexual activity for at least 4 weeks after each injection cycle 5
• Apply ice packs to the injection site for 20 minutes immediately after injection to minimize swelling 5
• Take ibuprofen 400 mg as needed for post-injection discomfort 2

Counseling Points:

• Expected outcome: Average curvature reduction of approximately 17° (compared to 9.3° with placebo), which is modest but meaningful for many patients 5, 1
• Common side effects include penile ecchymosis (bruising), swelling, and pain at injection site—84.2% of patients experience at least one adverse event, though most are mild to moderate 5, 1
• Rare but serious risk: Corporal rupture can occur; patients must avoid sexual activity during the restricted period 5, 1
• Treatment should be discontinued if curvature decreases to <15° 5
• This treatment addresses curvature only—it does not treat pain or erectile dysfunction 1
• Must be administered by a urologist experienced in treating Peyronie's disease 5

Alternative Intralesional Options (If Xiaflex Not Available or Appropriate)

Intralesional Interferon α-2b:

• Dosing: 5 million units (MU) every 2 weeks for 12 weeks (total 6 injections) 2
• Most appropriate for patients with stable disease (symptoms >12 months) 2
• Expected outcomes: Curvature reduction of 13.5° (vs 4.5° placebo), plaque size reduction of 2.6 cm² (vs 0.9 cm² placebo), pain resolution in 67.7% (vs 28.1% placebo) 2

Patient Instructions for Interferon:

• Expect flu-like symptoms, sinusitis, and minor penile swelling lasting <48 hours after each injection 2
• Take over-the-counter NSAIDs (ibuprofen 400-600 mg) for symptom management 2
• Maintain adequate oral hydration 2

Intralesional Verapamil (Conditional Option):

• Dosing: 10 mg injected into plaque every 2 weeks for 6 months 2
• Evidence is weak with substantial uncertainty regarding efficacy 2
• Side effects include penile bruising, dizziness, nausea, and injection site pain 2

Treatments to AVOID

Do NOT prescribe:

• Extracorporeal shock wave therapy (ESWT) for curvature or plaque reduction—it does not work 2, 1
• Radiotherapy—should not be used 2
• Oral vitamin E, para-aminobenzoate (Potaba), colchicine, tamoxifen—no consistent evidence of benefit 6, 4

ESWT may be considered only for penile pain (not curvature), but given that pain typically resolves spontaneously, the utility is low 2.

Surgical Referral Criteria

Refer for surgical consultation if:

• Disease has been stable for 3-6 months AND conservative therapy has failed for 1 year 1, 3
• Curvature prevents sexual intercourse 3, 7
• Patient has concomitant erectile dysfunction refractory to medical therapy 1, 8

Surgical options include:

• Tunical plication for curvature <60° with preserved erectile function 9
• Plaque incision/excision with grafting for curvature >60° or complex deformities 9, 8
• Penile prosthesis implantation for patients with erectile dysfunction 9, 8

Common Pitfalls to Avoid

• Do not treat active phase disease with intralesional injections—wait for disease stabilization 1
• Do not prescribe oral therapies as monotherapy expecting significant curvature improvement—the evidence does not support this 6, 8
• Do not use Xiaflex for pain relief—it is specifically for curvature reduction in stable disease 1
• Do not continue Xiaflex beyond 4 cycles or if curvature improves to <15° 5
• Ensure patients understand that average improvement with Xiaflex is modest (17°), and some may still require surgery 5, 1