What are the treatment options for Peyronie's disease?

Treatment Options for Peyronie's Disease

Disease Phase Classification Determines Treatment Strategy

Treatment for Peyronie's disease is fundamentally determined by whether the disease is in the active or stable phase, as these phases require completely different therapeutic approaches. 1

Active Disease Phase (First 3-12 Months)

Active disease is characterized by:

• Dynamic, changing symptoms with penile or glanular pain (with or without erection) 1
• Developing plaques and deformities that are not fully formed 1
• Progressive penile curvature 1

For active disease, oral NSAIDs are the first-line treatment for penile pain. 2, 3 Pain should be assessed using a visual analog scale and periodically reassessed to measure treatment efficacy. 2

PDE5 inhibitors (such as tadalafil 5mg daily) may be considered during the active phase to reduce collagen deposition and potentially lower curvature progression rates. 2, 3

Stable Disease Phase (Symptoms Unchanged ≥3 Months)

Stable disease is characterized by:

• Symptoms clinically unchanged for at least three months 1
• Pain typically absent or minimal 1
• Established, palpable plaques on examination or ultrasound 1
• Stable penile curvature (uniplanar or biplanar) 1

Non-Surgical Treatment Options for Stable Disease

Intralesional Collagenase Clostridium Histolyticum (Xiaflex)

Intralesional collagenase is the only FDA-approved non-surgical therapy for Peyronie's disease and represents a moderate recommendation for patients with stable disease. 2, 3

Specific indications:

• Curvature between 30° and 90° 2, 3
• Palpable plaque confirmed on physical examination 2
• Intact erectile function without need for medications 1, 2
• Stable disease without active progression 2

Treatment protocol:

• Up to 8 injections of 0.58 mg (10,000 U) over 24 weeks 1, 2
• Combined with clinician and patient modeling 1
• Average curvature improvement approximately 17° versus 9.3° with placebo 2

Critical caveat: Collagenase treats curvature only—it does not treat pain or erectile dysfunction. 2 Using collagenase for pain relief represents off-label use not supported by guidelines and could delay appropriate pain management. 2

Adverse events occur in 84.2% of patients, mostly mild to moderate, including penile ecchymosis, swelling, pain, and rare but serious complications like corporal rupture. 2

Penile Traction Therapy

Penile traction therapy can be offered for collagen remodeling but requires extended daily use. 2, 3 This represents a weaker evidence option compared to collagenase. 3

Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT)

LI-ESWT may be considered for pain relief but not for curvature reduction. 2, 3

Observation

For mild curvature not interfering with sexual function, observation is an appropriate option. 2, 3 Careful counseling about the disease nature and typical course may be sufficient to alleviate concerns, and patients may choose not to pursue additional treatment. 4

Surgical Treatment Options

Surgery should only be considered after disease has been stable for at least 3-6 months and conservative therapy has failed for approximately 1 year. 3, 5

For Patients with Preserved Erectile Function

Tunical plication (Nesbit procedure):

• Indicated for curvature <60° in penises with adequate length 5
• Shortens the convex side to straighten the penis 6, 5
• Results in some penile length loss 6, 5
• Appropriate when erectile function is adequate 5

Plaque incision/excision with grafting:

• Indicated for curvature >60°, hourglass or hinge deformities, and short penises 5
• Lengthening procedure using vein (saphenous) or dermal graft 6, 5
• Requires adequate erectile function 5

For Patients with Concurrent Erectile Dysfunction

Penile prosthesis implantation is the treatment of choice for patients with Peyronie's disease and refractory erectile dysfunction. 3, 7, 6 This addresses both issues simultaneously and is associated with high patient satisfaction. 7

Inflatable penile prosthesis should be used rather than semi-rigid devices, as modeling to maximize curvature correction is difficult with semi-rigid devices. 1

Essential Diagnostic Evaluation

Clinicians should perform an in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound prior to invasive intervention. 1, 3 This enables assessment of:

• Penile deformity in the erect state 1
• Plaque size and characteristics 1
• Pain during erection 1
• Erectile function status 3

Treatments with Insufficient Evidence

The following treatments lack sufficient evidence to support their use and should not be prescribed: 1, 3

• Oral vitamin E 1, 3
• Colchicine 1
• Tamoxifen 1
• Pentoxifylline 1
• Potassium aminobenzoate 1
• Topical verapamil 1
• Various combination therapies 1

Psychosocial Impact and Quality of Life Considerations

54% of men with Peyronie's disease report relationship difficulties, and depressive symptoms remain consistently high over time, indicating lasting psychological impact. 1, 4 Men express concerns about penile appearance, negative impacts on masculine self-image, decreased sexual confidence, and anxiety in sexual situations. 1

Critical Clinical Pitfalls to Avoid

• Do not use collagenase for pain management—it treats curvature only, not pain or erectile dysfunction 2
• Do not proceed with surgery until disease has been stable for at least 3-6 months 3
• Do not prescribe oral therapies like vitamin E, colchicine, or tamoxifen—they lack consistent evidence of efficacy 1, 3
• Do not use semi-rigid penile prostheses—inflatable devices allow necessary modeling 1
• Ensure collagenase is only administered by clinicians experienced in urological disease treatment 2
• Set realistic expectations—average curvature improvement with collagenase is modest (approximately 17° versus 9.3° placebo) 2