What are the treatment options for Peyronie's disease?

Treatment Options for Peyronie's Disease

Initial Assessment and Disease Classification

The first critical step is determining whether the disease is in the active or stable phase, as this completely dictates treatment strategy. 1

Active Phase Characteristics:

• Penile pain with or without erection, dynamic and changing symptoms, and incompletely developed plaques and deformities 1
• Typically lasts 3-12 months from symptom onset 2

Stable Phase Characteristics:

• Symptoms unchanged for at least 3 months, minimal or absent pain, established curvature, and palpable or ultrasonographically visible plaques 1
• Disease typically stabilizes at 12-18 months after symptom onset 3

Essential Diagnostic Evaluation:

• In-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound to assess penile deformity, plaques, and pain in the erect state 1

---

Treatment Algorithm by Disease Phase

Active Phase Treatment (Pain and Progression Management)

Oral NSAIDs are the first-line treatment for penile pain during the active phase. 1, 2

• Pain should be assessed using a visual analog scale and periodically reassessed to measure treatment efficacy 2

Consider daily tadalafil 5mg to reduce collagen deposition and decrease curvature progression. 1, 2

Avoid ineffective therapies:

• Do NOT use radiotherapy—it provides no benefit over natural disease progression and exposes patients to unnecessary radiation risks 3
• Extracorporeal shockwave therapy (ESWT) has low overall utility, as penile pain commonly resolves over time regardless of intervention 3

---

Stable Phase Treatment (Curvature Correction)

For Mild Curvature (Not Interfering with Intercourse):

• Observation is appropriate, as many patients function adequately with mild deformity 2
• Careful counseling about disease nature and typical course may be sufficient to alleviate concerns 1

For Moderate Curvature (30-90 degrees) with Intact Erectile Function:

Intralesional collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved non-surgical therapy for stable Peyronie's disease. 1, 2

• Requires palpable plaque on physical examination and stable disease without active progression 2
• Protocol involves up to 8 injections of 10,000 U (0.58 mg) over 24 weeks, combined with clinician and patient modeling exercises 2, 4
• Injections should be spaced 6 weeks apart between treatment cycles 4
• Average curvature reduction is 17° versus 9.3° with placebo 2, 4
• Critical caveat: Collagenase treats curvature only—it does NOT treat pain or erectile dysfunction 2
• Must be administered by clinicians experienced in urological disease treatment 2, 4
• Stop treatment if curvature decreases to <15° after treatment cycles 4

Common adverse events include:

• Penile ecchymosis, swelling, and pain (84.2% of patients experience at least one adverse event, mostly mild to moderate) 2, 4
• Rare but serious complications include corporal rupture 2, 4

Alternative non-surgical option:

• Penile traction therapy for collagen remodeling, though it requires extended daily use 2

---

Surgical Treatment (For Stable Disease with Significant Functional Impairment)

Surgery should only be considered when disease has been stable for at least 3 months and curvature compromises sexual function. 3, 1

Surgical Candidates Must Have:

• PD symptoms for at least 12 months 3
• Stable curvature for 3-6 months 3

Surgical Options Based on Erectile Function Status:

For patients with adequate rigidity for coitus (with or without PDE5 inhibitors/vacuum devices):

1. Tunical plication surgery (most common surgical approach, representing ~50% of PD surgeries) 3

   • Curvature improvement occurs in ≥90% of cases 3
   • Most appropriate for patients with intact erectile function or ED responsive to oral medications, vacuum therapy, or intracavernosal injections 3
   • Important caveat: Plication is NOT a treatment for ED, and consequences regarding erectile function remain unclear 3

2. Plaque incision or excision with grafting 3

   • Curvature improvement ranges from 25-100%, with majority of studies reporting >80% success 3
   • Relatively low risk of serious adverse events 3
   • Best suited for patients with intact erectile function or ED responsive to medical therapy 3

For patients with ED and/or penile deformity preventing coitus despite pharmacotherapy/vacuum therapy:

1. Penile prosthesis surgery 3
   • Curvature improvement >80% in all reviewed studies 3
   • Use inflatable penile prosthesis rather than semi-rigid devices, as modeling to maximize curvature correction is difficult with semi-rigid devices 3
   • Adjunctive intraoperative procedures (modeling, plication, incision/grafting) are frequently necessary to achieve optimal curvature correction and penile dimensions 3
   • No correlation between surgical complexity and infection/revision rates or patient satisfaction 3

---

Quality of Life and Psychological Considerations

Peyronie's disease significantly impacts quality of life, with 54% of men reporting relationship difficulties. 1

• Depressive symptoms remain consistently high over time, suggesting durable psychological impact 1
• Comprehensive counseling about disease nature and expected course is essential for all patients 1
• Some patients may choose no active treatment after thorough counseling 1

---

Critical Pitfalls to Avoid

• Do NOT offer radiotherapy—it provides no benefit over natural disease progression 3
• Do NOT use collagenase for pain management—it is specifically a curvature therapy, not a pain treatment 2
• Do NOT perform surgery during active disease phase—surgical outcomes for patients with active disease are unknown 3
• Do NOT use semi-rigid prostheses—inflatable devices allow necessary modeling for optimal outcomes 3
• Do NOT prescribe oral therapies as monotherapy—no strong data supports any oral agents alone for PD 5