What should be done for a 49-year-old male with erectile dysfunction, penile deformity (bent appearance), and dysuria (pain during urination) without any palpable masses?

Immediate Evaluation for Suspected Peyronie's Disease with Urinary Symptoms

This patient requires urgent urological evaluation for suspected Peyronie's disease with possible urethral involvement, as the combination of penile curvature, erectile dysfunction, and dysuria suggests disease progression that may include meatal or urethral stenosis.

Critical First Steps

Perform a comprehensive genital examination immediately, specifically:

• Examine the penis in stretched position, palpating from pubic bone to coronal sulcus for plaques or deformities 1
• Assess the urethral meatus for placement, configuration, and signs of stenosis 1
• Evaluate for penile skin lesions 1
• Note that absence of palpable plaques does NOT exclude Peyronie's disease—plaques may only be visible on ultrasound 1

The dysuria is particularly concerning because perimeatal involvement in Peyronie's disease can cause postinflammatory scarring leading to stenosis and urinary obstruction 1. This requires immediate attention to prevent progression to more proximal urethral involvement 1.

Essential Diagnostic Workup

Order an in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound to evaluate:

• Penile deformity in erect state 2, 3
• Plaque location and characteristics 2, 3
• Presence of pain during erection 2, 3
• Erectile function 2, 3

Obtain morning serum total testosterone levels as this is recommended for all men presenting with erectile dysfunction 1

Consider glucose/HbA1c and lipid panel as these may alter ED management 1

Determine Disease Phase

This classification completely dictates treatment strategy 2, 3:

Active phase indicators (typically 3-12 months from onset):

• Penile pain with or without erection 2, 3
• Dynamic, changing symptoms 2, 3
• Incompletely developed plaques 2, 3

Stable phase indicators (typically 12-18 months after onset):

• Symptoms unchanged for ≥3 months 2, 3
• Minimal or absent pain 2, 3
• Established curvature 2, 3
• Palpable or ultrasonographically visible plaques 2, 3

Treatment Algorithm Based on Phase

If Active Phase:

Start oral NSAIDs immediately for penile pain—this is first-line treatment 2, 3

Consider daily tadalafil 5mg to reduce collagen deposition and decrease curvature progression 2, 3

Avoid radiotherapy completely—it provides no benefit over natural disease progression and exposes patients to unnecessary radiation 3

If Stable Phase:

For moderate curvature (30-90 degrees) with intact erectile function:

• Collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved non-surgical therapy 2, 3
• Requires palpable plaque and stable disease without active progression 3
• Protocol: up to 8 injections of 10,000 U over 24 weeks with modeling exercises 3
• Average curvature reduction is 17° versus 9.3° with placebo 3
• Important caveat: Collagenase treats curvature ONLY, not pain or erectile dysfunction 3

For severe curvature compromising sexual function:

• Surgery is indicated only when disease has been stable for ≥3 months 2, 3
• Tunical plication is most common approach with ≥90% curvature improvement 3
• Penile prosthesis is appropriate for patients with both ED and deformity preventing intercourse, with >80% curvature improvement 3

Address the Urinary Symptoms Urgently

The dysuria requires immediate urological referral because:

• Perimeatal scarring can lead to stenosis and obstruction 1
• More proximal urethral involvement may develop 1
• This represents potential disease progression requiring specialized evaluation 1

Evaluate bladder function given the urinary symptoms, as diabetic autonomic neuropathy (if diabetes present) can cause lower urinary tract symptoms 1

Psychological and Quality of Life Considerations

Provide comprehensive counseling about:

• Disease nature and expected course 2
• 54% of men report relationship difficulties from Peyronie's disease 2
• Depressive symptoms remain consistently high over time 2

Consider referral to mental health professional to promote treatment adherence, reduce performance anxiety, and integrate treatments into sexual relationships 1

Critical Pitfalls to Avoid

• Do NOT delay urological referral given the urinary symptoms suggesting possible urethral involvement 1
• Do NOT perform surgery during active disease phase—surgical outcomes for active disease are unknown 3
• Do NOT use collagenase for pain management—it is specifically a curvature therapy 3
• Do NOT assume absence of palpable plaque excludes Peyronie's disease—additional diagnostic procedures are needed when suspected 1